Cryotherapy

this ppt includes
Indications
Contraindications
Techniques
Post procedure care
Complications
Advantages & disadvantages

1. CRYOTHERAPY

2. Cryotherapy Indications Contraindications Techniques Post procedure care Complications Advantages & disadvantages

3. INDICATIONS - BENIGN Warts Molluscum contagiosum Cystic acne , acne scars Keloid Prurigo nodularis Milia Pyogenic granuloma Skin tags Seborrheic keratoses Mucosal Lichen planus Acne keloidalis Angiomas Cherry angiomas Chromoblastomycosis Cut. Leishmaniasis Epidermal nevus Granuloma annulare Mucocoele Sarcoidosis Syringocystadenoma papilliferum Xanthoma

4. INDICATIONS Leukoplakia Bowen’s disease Actinic keratoses Erythroplasia of Queyrat BCC SCC Lentigo Maligna PREMALIGNANT MALIGNANT

5. CONTRAINDICATIONS Agammaglobulinemia Cold intolerance Cold urticaria Cryoglobulinemia Raynaud’s disease Collagen Vascular diseases Multiple myeloma Absence of accurate diagnosis Melanoma

6. DEFINATIONS TARGET AREA : Extent of the lesions both peripherally and in depth FREEZE TIME : Elapsed time from the start to the end of the freeze cycle COMPLETE THAW TIME : Elapsed time from stopping the cold application until the lesion is thawed. HALO-THAW TIME -elapsed time from stopping cold application until thaw reaches area where cold was applied

7. PRE-PROCEDURE Biopsy to confirm the diagnosis(Malignant , premalignant lesions.) Photographs HIV, VDRL screening , if required Informed and written consent Analgesics may be given 1-2 hrs before procedure

8. PROCEDURE CRYOGEN METHOD LIQUID NITROGEN DIPSTICK, ROLLER, SPRAY, PROBE CO2 CRYOSLUSH, PROBE NITROUS OXIDE PROBE

9. Cryogen Effective temperature (°C) Ice Salt Ice -20 Flurocarbons ( freons ) - 29.8 /-30 Nitrous Oxide - 89.5 /-75 CO2 - 78.5 /-79 (snow ) -20 (slush) Liquid Nitrogen -20 (swab) - 195.8 /196 (spray/probe) Cell Temperature (°C) Melanocytes -4 to - 8 Keratinocytes -20 to -30 Dermal connective tissue & fibroblast -30 to -40

10. LIQUID NITROGEN DIP STICK METHOD Cotton tipped applicator Dipped in liquid nitrogen Applied firmly on to the lesion till a narrow halo forms around the lesion Temperature obtained : – 20 o C Suitable for treating only superficial lesions Disadvantages: lack of control, slow and inadequate freezing

11. LIQUID NITROGEN CRYO – ROLLER The metallic cylindrical roller end is dipped in the liquid nitrogen Rapidly rolled over acetonized surface of the lesion Nodulocystic acne, acne scars, keloid , hyperthrophic scars Minimises surface necrosis,ulceration Minimises Pigmentary changes

12. LIQUID NITROGEN SPRAY TECHNIQUE

13. SPRAY TECHNIQUE Cryo spray is filled upto 2 inches from the brim. Wait for 3-4 mins for the pressure to build up Anaesthesia – if required Mark the periphery of the lesion Rim of normal skin to be included: benign: 1- 2 mm, premalignant: 3-5mm , malignant 5-10 mm Spray tip held 1 cm away from the lesion and steady spray is directed at the lesion Ice field extends upto marked periphery

14. SPRAY TECHNIQUE The ice ball is maintained for the required time Lesion allowed to thaw slowly ( usually X2 freeze time) Repeat freeze thaw cycle if indicated. Skin to be palpated to confirm disappearance of ice ball from tissue.

15. TYPES OF SPRAY TECNIQUES Depending upon shape and size of lesion being frozen Spot freeze technique Useful for treating lesions < 2 cm ( ice field upto 2 cm) Maximum depth of adequate ice formation in the centre of the lesion is 0.5 to 0.6 cm and the temperture attained is -40 C to – 60 C If lesion > 2 cm in diameter then overlapping 2 cm diameter circles treated separately. Paint Brush Technique Spraying started at lateral point of lesion & done back and forth – horizontally or vertically. Useful for irregular and larger lesions

16. TYPES OF SPRAY TECNIQUES Spiral spray Technique Freezing started at the centre and then carried along widening spirals Rotatory Technique Multiple concentric circles of increasing diameter to cover whole of the lesion

17. SPRAY TECHNIQUE USING CONES/CYLINDERS Also known as RESTRICTED SPRAY TECHNIQUE Advantages: Spray is concentrated Lateral spread is restricted Gives a rapid rate of freezing – more destructive Useful at site like eyelids/ inner canthi where lateral spread has to be restricted

18. CRYOPEEL SPRAY TECNIQUE USING ACNE TIP Using split tip spray accessory Indications Nodulo -Cystic acne Post acne scarring Acne Keloidalis nuchae Procedure to be reserved for fair and wheatish complexioned individuals. One should not wait for the ice ball formation, occurrence of blanching – end point Depending upon the time peel – superficial – 2-3 secs / deep- 5-7 secs

19. PROCEDURE Written informed consent Marking – Skin surface is divided into segmental squares of 4 cm 2 each. Pt in upright position – eyeglasses/ plastic apron. Special acne spray tip attachment ( slit like opening) used – each square sequentially sprayed in paint brush or shaving razor method for 2-7 sec Slight feathering done at the submandibular margin

20. POST PROCEDURE Severe edema on 2 nd day with blistering ( 2-3 days) which gradually subsides with crusting and peeling. Calamine lotion 2-3 days Emollients during crusting phase Anti inflammatory medications X 5 days Sun protection X 6-8 wks Ct. anti acne treatment S/E – erythema , hyper/hypo/ depigmentation , burns, scarring Minimum gap of 8-12 weeks between two sessions if required

21. CRYOPROBE TECHNIQUE Liquid nitrogen circulated to cool the tip of the cryoprobe Cryoprobe then applied to the lesion Freezing by conduction Slower than spray technique

22. CRYOPROBE

23. METHOD Spray Unit is filled with liquid nitrogen, lesion is marked, LA if required. Probe suitable for the lesion – 3/4 th size of the lesion, different shapes- pointed, flat, rounded. Surgical gel applied onto the lesion ( for hydration and better probe contact) Probe applied- adheres to skin within 5-6 secs .

24. METHOD Probe retracted from the skin to protect surrounding tissues. Depending upon the depth required pressure is applied. Adequacy of freeze checked –by extent of rim of normal tissue frozen Probe is allowed to thaw before removal from treatment site. Repeat cycle if required after adequate thawing of the lesion.

25. INTRALESIONAL TECHNIQUE Passing long metallic cryoprobe needles through the deeper portion of bulky lesion. Spraying of LN 2 through the needle- resolution of lesion. Avoids normal tissue destruction as seen with spray / cryoprobe technique

26. 5-MM AND 10-MM PENETRATING CRYOPROBES, AS WELL AS A SURFACE DISC-TYPE CRYOPROBE.

27. CRYOSLUSH WITH LIQUID NITROGEN Indications- nodulocystic acne,acne scarring A square gauze piece held with a long artery forceps dipped in LN2. Acetone is applied and then gauze is applied for 2-10 seconds Superficial peeling is achieved due to epidermal necrosis which causes desquamation of comedones,resolution of inflammatory papules

28. NITROUS OXIDE Cryoprobe technique Cryoprobe attached to a nitrous oxide cylinder CARBON DIOXIDE Cryoprobe technique Cryoslush Technique

29. CRYOSLUSH TECHNIQUE Using CO2 crystals along with acetone with/ without precipitated sulphur and / or alcohol for superficial peeling of skin - desquamation of comedones , resolution of papules, pustules, nodulocystic acne – causes avoidance / improvement in superficial acne scars. Effective Skin temp achieved – 20 C

30. CRYOSLUSH TECHNIQUE Acetone Dissolves sebum, allows easy slippage of CO2 crystals over face ( avoids cryoinjury ) Precipitated Sulphur Antibacterial and superficial keratolytic Ethyl Alcohol Dissolves sebum, allows easy slippage of CO2 crystals over face ( avoids cryoinjury )

31. EQUIPMENTS CO2 Cylinder Copper tubing Chamois leather bag

32. INDICATIONS Cystic and Nodular acne Post acne scarring Acne Keloidalis nuchae

33. PROCEDURE Written and informed consent Pt. in supine position Collect solid ice in chamois bag from CO2 cylinder by holding it tightly enclosing the end of copper tubing attached to cylinder Crush it in a bowl with few drops of acetone to form a paste Applied with a gauze ball/ glass rod sequentially to cover the entire face. End point – blanching of the skin Duration –ranges from 2-10 sec. depends upon severity and complexion (less duration for dark complexioned individuals) Immediately on application frosting and blanching appears f/by erythema . Peeling in 2-4 days.

34. POST PROCEDURE Calamine lotion to be applied for 2-3 days for faster desquamation. Sun protection X 1 week Continue medical therapy for acne S/E Hyper/ hypopigmentation

35. LN2 cryoroller - ACNE It lowers surface temp to -196 0 c Its superficial depth peeling action causes desquamation, reduces inflammation – faster resolution of acne Remodels the dermal collagen – to improve existing scars Rapid movement of roller ensures short contact time , & hence complications like hyperpigmentation and scarring avoided /minimized.

36. Indications- Nodulo cystic acne (grade- 3 ,4) Acne scars(atrophic , rolled on, superficial box scars) Contraindications- Deep box scars and ice-pick scars Procedure- Pt in supine position with head elevated at 45 0 Pour LN2 into thermacol cup, dip cylindrical metalic end of roller into it. Roller rapidly rolled over face sequentially, covering one unit at a time, with uniform pressure. Minimum pressure over bony promineces Feathering done at sub mandibular borders, hairline.

37. Precaution taken to keep skin surface always moist with acetone (assistant instructed to apply acetone to segment just prior to rolling) Severely inflammed lesions treated second time. Base of individual scar t/t with cotton swab dipped in LN2 & pressed against base for 1-2 sec. Post procedure- Calamine lotion for 2-3 days,sun protection, medical therapy for acne continued with short course of anti inflammatory drugs. Schedule- every 2-3 wks till complete resolution of inflammed lesions.

38. Hypertrophic scars & Keloids LN2 CRYOSPRAY LN2 CRYOPROBE LN2 CRYOROLLER- Useful for flat surfaced keloid with height 0.5 to 1cm. There is direct cell destruction along with vascular stasis causes tissue necrosis and sloughing Profound effect on collagen,fibroblasts resulting in collagen remodelling Healing occurs in 3-4 wks wth reduction in tissue mass

39. LN2 INTRALESIONAL CRYO - Hypertrophic Scars and large bulky keloids with ht more than 1cm. involves passing multiple needles midway thro the lesion & inducing cryo injury at a depth, thus sparing surface. useful for debulking large lesion. Freeze time of 30 sec required & repeat after 1mnth interval, until flattening of lesions.

40. Viral infections Warts – Liquid nitrogen is used to deep freeze the wart tissue. With liquid nitrogen applied to the wart, the water in the cells expands, thus exploding the infected tissue. The exploded cells can no longer hide the human papilloma virus from the body's immune system. The immune system then works to destroy the virus particles. Using spray technique most common d/t its quick convenient use. Response is variable & depends on the size of the wart and the degree of hyperkeratosis. Several treatment sessions typically are required, and the overall success rate is approximately 75 %

41. To avoid hypopigmentation , small flat warts may be treated with a light spray technique. Paring of warts before cryo improved cure rates for plantar warts. Deep plantar or palmar warts present challenges, because pain may limit the patient’s tolerance of freezing. However, favorable cure rates have been reported for initial pretreatment with keratolytics (salicylic acid) Cryosurgery has been found to be effective in the management of condyloma acuminatum , particularly when treatment with podophyllin has failed. Molluscum contagiosum Lesion is amenable to cryosurgery, if indicated.Applying liquid nitrogen spray for a few seconds until the surface of the umbilicated papule turns white usually is adequate.

42. MALIGNANT LESIONS Temperature monitoring is useful while treating skin malignancies. Single thermocouple needle for small lesions and 2-3 needles for bigger tumors. TECHNIQUE Informed and written consent. Mark margins with 5-10 mm excess. Local Anesthesia injected Thermocouple needle inserted Open Spray/ Restricted spray/ cryoprobe method

43. MALIGNANT LESIONS Freezing done upto 5-10 mm of surrounding area Freezing continued till a temp -50 C is reached which indicates necrosis of all malignant cells Freeze time 1 ½ mins with a thaw time of 3 mins . Second freeze thaw cycle is then carried out, after 3-5 min. When freezing tumors in ear, one should freeze till the ice frost is seen on the other side of the ear. Tumors on the eyelids can be frozen after protecting the eye with a plastic eye retractor.

44. BCC Several studies reported treating BCC with cryo - cure rates between 95 -99% The cryogen produces cellular damage by intra and extra cellular ice crystal formation, vascular stasis and local electrolyte imbalance.Collagen fibres, cartilage and bone are resistant to damage by cryogen which enables healing and allows selective destruction of tumors overlying bone or cartilage The advantages are it is a simple office procedure, cost effective and can be used in those with medical risk for surgery. Disadvantages include prolonged healing time, depigmentation and scarring. Recurrences usually occur during first 2 years after treatment.  In a recent study Kuflik and Gage treated recurrent BCCs ranging in size from 0.6 to 4.4 cms with cryotherapy and found it to be effective and the results comparable with other methods of treatment.

45. Lentigo Maligna Effective modality d/t sensitivity of melanocytes to cold. A clinical margin of 5mm drawn around visible borders Treated with double freeze- thaw cycle of 30-60 sec. Adv- effective & avoidance of large surgical scars Disadv - inability to assess complete destruction of lesion & As no tissue obtained for definitive confirmation of cancer removal – chance for recurrence of melanoma.

46. CHANGES AFTER CRYOSURGERY WITHIN FEW MINUTES

47. POST PROCEDURE CARE BENIGN Medications Dressing – topical antibiotic, drain blister with sterile needle f/u after 15 days to assess the lesion Procedure can be repeated after 3 weeks if required MALIGNANT Medications Dressing: steroid + antibiotic Course of wound – dry black adherent crust appears after 10-14 days, falls of after about a week ; upto a month- pink scar f/u – weekly till crust falls off ( 4-6 weeks) ; every 3-6 mths for 4-6 yrs for recurrence

48. FREEZE TIME BENIGN SKIN CONDITION FREEZE TIME Viral warts 15-20 secs Molluscum contagiosum 5-10 secs Seborrheic keratoses 10-15 secs Acne cysts/ scars 2-7 secs Skin tags 5-10 secs Keloid 20-30 secs Prurigo nodularis 20-30 secs PREMALIGNANT LESIONS FREEZE TIME Solar keratoses 5-15 secs Bowen’s disease 20- 30 secs Leukoplakia 25- 30 secs

49. FREEZE TIME MALIGNANT LESIONS Using HPE – depth of the tumor ascertained Minimum two 30 secs freeze-thaw cycles with a 5 min thaw between each freeze. Depth and adequacy of freeze – thermocouple needles.

50. COMPLICATIONS IMMEDIATE Pain, Headache Edema, blister formation Syncope, febrile reaction DELAYED Post operative infection Hypertrophic granulation tissue formation Temporary Hyperpigmentation Milia Hypertrophic scars Arthralgia Nerve damage Paraesthesia DELAYED ( permanent) Hypo or depigmentation Atrophy Cicatricial alopecia Ectropion Notching of eyelids

51. ADVANTAGES Simple,safe , cost effective procedure OPD procedure – no need for hospitalisation Can b used alone / combined with other surgical modalities ( curretage , paring.) Cure rates are high in properly selected cases Palliative therapy for inoperable tumors Excellent cosmetic results No general anaesthesia; local anaesthesia optional Useful in pregnancy For patients who are fearful of undergoing surgery For poor surgical risk patients All ages can be treated – also pts. at poor risk for surgery. Useful in HIV individual – being a no touch technique.

52. DISADVANTAGES Discomfort like stinging, burning/ pain Multiple sittings may be required Hyper/ hypo/ depigmentation – dark complexioned individuals. Availability may be a problem in small towns

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