Cryosurgery is a well proved method for treatment of the benign and malignant lesions of the skin, but there are instances in some particular cases when cryosurgery is a method superior to other methods.
In this paper I will give you my preferences during 17 years of performing the procedure.
The first and most important aspect of this is the experience of the dermatologist and its training in cryosurgery, with the time and the knowledge of the final outcome of certain tumors he or she will be able to have some preferences in the treatment of certain lesions.
One of the important factors that we have to consider is the type of lesion that we are going to treat, the depth of the lesion, also the number of lesions that we are going to treat.
According to the depth of the lesion, when we are treating a superficial lesion or lesions that are affecting only the epidermis is possible that we will have a very good results, for example lesions like actinic keratosis or seborrhoic keratosis, in this cases we have to be aware of the amount of keratin in every lesion, because it is well known that keratin is not a very good conductor of the temperature, then is important to remove some keratin before the application of cryosurgery. When we are treating flat warts in the face the results are going to be good because they are epidermal lesions without a great amount of keratin covering the lesions. But when we are epidermal lesions without a great amount of keratin like periungeal warts and plantar warts we have to remove the keratin first by using saliclic acid some weeks prior to freeze the lesion. We can obtain a very good results in hyperpigmented lesions like the lentigines in the dorsa of the bands and in the forearms. But in cases of lentigo in the face the results can not be so wonderful, I prefer in this patients to prepare them with two months use of sun screen and in pigmented people with the use of hydroquinone cream 25% at night two months prior performing the cryosurgery.
When we are treating and exophytic lesions like skin tags in the neck or in the axilla the lesions are completely out of the surrounding skin and we will obtain a very good results, this is also true in cases of exophytic condiloma acuminata, in this particular cases is important to begin the freezing from the bottom of the lesion to the top and if it is an exophytic lesion I prefer to use the cryohemostatic probe.
In the epidermal lesion it is important to freeze only the tumor and not to obtain an halo of freezing because there is no lesion in the dermis.
According to the time needed for the destruction of lesions it is very variable and depends on direct proportion on the mass to be frozen, great, masses take long time to be frozen and small masses short time.
When we have epidermal-dermal lesions: we have to freeze the tumor and obtain a I mm 2mm halo of normal skin, in this lesions we can have as a final result some degree of hypopigmentation and in some case hyperpigmentation.
Some examples of the are:
Mofuseum contagiosum is a epidermal-dermal lesion, in this cases I recommend the use of a I to two mm probe and applying some pressure to the probe, another measure that now we are using is 45 min. prior to the procedure the application of EMLA cream.
Some other andexal tumors are epidermal and dermal like the syringomas of the eyelids and the use of probe obtaining I mm halo will give us a good result. The same is true in the case of multiple trychoepitelioma as my two favorite andexal tumors suitable to be treated with cryosurgery.
In the case of the vascular lesions like the hemangiomas of flebectasias we have to apply a probe and pressure in order to freeze the posterior walls of the vascular malformation. Do to the depth of the lesions treated we can anticipate some scars, that will improve with the time.
When we are dealing with cysts like mixoid cyst of the fingers I prefer to perform an intralesional cryosurgery, this consists in making an small incision express the content and introduce a small 2 mm probe in to the cavity freezing the lesions until is completely frozen, in this way we will freeze the walls of the tumor that are located into the dermis and avoid damage to the epidermis, with this technique we will obtain less recurrences and less scar in the epidermal tissue.
Cryosurgery is good method for treating mucocceles on the lips, in this cases I use a chalagion hemostatic and a probe of the same shape of the lesion in the same way that has been described for hemangiomas. It is important to tell the patient that this procedure will give him a very strong inflammation and we use intramuscular systemic steroids the same day of the procedure.
In the malignant lesion I prefer to treat only basal cell carcinoma, nodular type located on the nose, on the ears, and on the eyelids with delimitable clinical margins by shaving the exophytic part of the tumor, performing a coagulation of the base by Radiosurgery and then cureting. After that I perform the double freeze technique using spray, probe or a cryochamber reaching with digital thermometer-50 degrees centigrade.
Some small Epidermoid Carcinomas are suitable to be treated if there are continue indications for performing a surgery.
In Conclusion: The case described above are the best indications that I personally consider a first choice options for performing cryosurgery.
Bibliography:
1. Kuflik F.G. Cryosurgery Updated J. Am Acad Dermatol 1994,31:925-44.
2. Torre D. Lubritz I, Kuflik E. Practical Cutaneous Cryosurger. Igaku Shoin Ed 1990 11-83.
3. Zacarian S. Cryosurger for Skin cancer cutaneous disorders Ed Mosby 1985. 45-58.
4. TuzJansky E. Stolar E. Cryosurgery of Beningn and malignant affections Cryornedicac 1992. 127-130.
5. Bolder Sommeregger K. Pewtrovic S. Reactive lentiginosis after Cryosurgery for lentigo maligna J. Am Acad Dermatol 1992. 523-526.
6. Goldshleger G. Cryostugical. treatment of hemangiomas of the lip. Oral Surg Med Oral Pathol 1992:73:650-654.