Cryosurgery and Electrosurgery

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

 Tissue destruction: -10 to -20 C.

 Malignant cell kill: -40 to -50 C.

 Chemical refrigerants -70 to -94 C.

 Cold cryoprobes -90 C.
 Liquid Nitrogen -196 C.
 Chemical Refrigerants

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

 Nitrous oxide cryoguns

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

 Put water soluble gel to lesion

 Select probe size
 Apply activated cryogun probe tip to skin
 Liquid Nitrogen

Advantages for clinician

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

Advantages for patient

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

Disadvantages for clinician

 Start-up costs $1000
 Storage facilities
 Filling canisters
 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
 Liquid Nitrogen: Equipment
 Liquid nitrogen
 Storage tank= Dewars
 2-30 L, filled q 3-4 weeks
 Costs:
Tanks: Holding time Costs
» 2L 48 hrs $200
» 10 L 6-8 weeks $475
» 20 L 8-12 weeks $535
» 30 L 14-16 weeks $620
 Liquid Nitrogen: Equipment
 Filling Dewars; pouring, ladles or devices
 Devices affixed to dewar:
Ladels Valve: $310 Tube: $150
 Liquid Nitrogen: Equipment
Thermos bottle with hole and cotton tipped swab or
Cry-AC Spray/cryogun (C-tip, mini-gun)

10 oz 16 oz 12 oz
$670 $670 $650
12 hr 24 hr
24 hr
 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
 Cryosurgery

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

 Informed consent-oral vs written

Cryosurgery: Freezeball Time

 Freckles/lentigos: 3-5 seconds

 Small papules: 5-10 seconds
 Seborrheic Keratoses: 30-40 seconds
 Actinic keratoses: 40-60 seconds
 SCCa/BCCa: 80-90 seconds
 Cryosurgery: Freezeball Size

 1mm- freckles/lentigos
 1-2 mm- most benign skin lesions
 2-3 mm- most warts
 3-4 mm- most actinic keratoses
 4-6 mm- superficial SCCa, BCCa
 Cryosurgery

 Thermocouple

 $500 for temperature

monitor and thermocouple
needle
 Cryosurgery: Effectiveness

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

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

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

 Verruca:
» Often resistant
» Warts on hands
» Plantar warts
» Flat warts
 Cryosurgery: Effectiveness

High
 Actinic keratosis
 Superficial Basal Cell Carcinoma
 Superficial Squamous Cell Carcinoma
Cryosurgery: Superficial BCCa/SCCa

 Establish pathological diagnosis first

 Success rates > 95%
 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
 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
 Cryosurgery

BE CAREFUL ABOUT FREEZING

 Lesions on/near the eye
 Lesions on the fingers/elbows
 Lesions over shins, ears, genitals
 Lesions near nails
 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
 Cryosurgery: Side Effects

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

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

 Purpose:
» Destroy tissue
» Excise tissue
» Coagulation
 Often done with curettage
 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
 Electrosurgery

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

Indications Procedure
 Cherry angiomas dessication
 Achrocordans dessication/fulguration
 Telangiectasias dessication
 Small verrucae on hands fulguration
 Pyogenic granulomas fulguration
 Seb Keratoses fulguration
 Small BCCa or SCCa fulguration and curettage
Resistant Wart
 Electrosurgery
 Start at low power and increase slowly
 Use lowest power needed for tissue
destruction/cutting
 Electrosurgery
 Local anesthesia: EMLA, lidocaine
 Avoid ethyl chloride, alcohol wipes, and
oxygen
 Keep field dry (Aluminum chloride)
 Mask and ventilation
 Fire extinguisher
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”
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
Electrosurgery vs Cryosurgery

 Verrucae and AK’s- Cryosurgery

 Condyloma- Electrosurgery

(Transmission of HPV through vapors)

 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
 Electrosurgery and ....

 Pacemakers
 Metal pins
 Melanoma
 Conclusions

 Cryosurgery and elctrosurgery are safe,

effective and can be done quickly
 Know the diagnosis first
 Perform patient education before the
procedure
 THE END

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