Cutaneous Cryosurgery for Common Skin Conditions

Karl T. Clebak; Megan Mendez-Miller; Jason Croad

Apr 1, 2020 Issue

Cutaneous Cryosurgery for Common Skin Conditions

KARL T. CLEBAK, MD; MEGAN MENDEZ-MILLER, DO; and JASON CROAD, DO; Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania

Am Fam Physician. 2020 Apr 1;101(7):399-406.

Author disclosure: No relevant financial affiliations.

Cryosurgery is the application of freezing temperatures to achieve the destruction of tissue. Cutaneous cryosurgery has become a commonly performed outpatient procedure because of the combination of its safety, effectiveness, low cost, ease of use, lack of need for injectable anesthetic, and good cosmetic results. Cryosurgery may be performed in the outpatient setting using dipstick, spray, or cryoprobe techniques to treat a variety of benign, premalignant, and malignant skin lesions with high cure rates. Benign lesions such as common and plantar warts, anogenital condylomas, molluscum contagiosum, and seborrheic keratoses can be treated with cryotherapy. Basal and squamous cell carcinomas with low-risk features may be treated with cryosurgery. Contraindications to cryosurgery include neoplasms with indefinite margins or when pathology is desired, basal cell or squamous cell carcinomas with high-risk features, and prior adverse local reaction or hypersensitivity to cryosurgery. Potential adverse effects include bleeding, blistering, edema, paresthesia, and pain and less commonly include tendon rupture, scarring, alopecia, atrophy, and hypopigmentation.

Cryosurgery is the application of freezing temperatures to achieve the destruction of tissue.1 Cryosurgery is an effective and efficient method for treating a wide range of cardiac, dermatologic, ophthalmic, gynecologic, oncologic, neurologic, and urologic conditions. Cutaneous cryosurgery has become a commonly performed outpatient procedure because of its safety, effectiveness, low cost, ease of use, lack of need for injectable anesthetic, and good cosmetic results.1

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Cryosurgery is useful in the treatment of actinic keratoses with cure rates reported between 69% for freeze times of more than five seconds and 83% for freeze times of more than 20 seconds.¹⁸	B	Limited evidence from single randomized controlled trial
Warts may be treated with cryotherapy administered at two-, three-, or four-week intervals without differences in cure rates.²¹	A	Cochrane review with clear recommendation
Cryosurgery is as effective as daily treatment with salicylic acid in the treatment of plantar warts, with higher reported patient satisfaction.²²	B	Limited evidence from single randomized controlled trial

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Cryosurgery is useful in the treatment of actinic keratoses with cure rates reported between 69% for freeze times of more than five seconds and 83% for freeze times of more than 20 seconds.¹⁸	B	Limited evidence from single randomized controlled trial
Warts may be treated with cryotherapy administered at two-, three-, or four-week intervals without differences in cure rates.²¹	A	Cochrane review with clear recommendation
Cryosurgery is as effective as daily treatment with salicylic acid in the treatment of plantar warts, with higher reported patient satisfaction.²²	B	Limited evidence from single randomized controlled trial

Mechanism of Action

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Abstract
Mechanism of Action
Equipment/Techniques
Treatment/Clinical Application
Contraindications
Complications
Postoperative Care
Billing
References

Commonly available cryogens include Freon 12, Freon 22, solid carbon dioxide, liquid nitrous oxide, liquid nitrogen, and liquid helium.2 The freons are typically used for skin anesthesia. Liquid nitrous oxide is effective in treating benign skin lesions; however, it is more commonly used for ophthalmic and gynecologic lesions. Liquid nitrogen has become the cryogen of choice in most clinical situations.3

Temperatures of −13°F to −58°F (−25°C to −50°C) can be achieved with liquid nitrogen within 30 seconds when using a spray or probe. Effective removal of malignant lesions typically requires lower temperatures (−40°F to −58°F [−40°C to −50°C]) achieved with the application of spray or probe. Liquid nitrogen used with the applicator method is useful in treating premalignant and benign lesions, requiring slightly higher temperatures of −4°F to −22°F (−20°C to −30°C).3

The mechanism of injury includes the direct effects of freezing on the cells, osmolarity

The Authors

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KARL T. CLEBAK, MD, FAAFP, is an assistant professor and residency program director in the Department of Family and Community Medicine at Penn State Health Milton S. Hershey (Pa.) Medical Center....

MEGAN MENDEZ-MILLER, DO, is an assistant professor in the Department of Family and Community Medicine at Penn State Health Milton S. Hershey Medical Center.

JASON CROAD, DO, is an assistant professor in the Department of Family and Community Medicine at Penn State Health Milton S. Hershey Medical Center.

Address correspondence to Karl T. Clebak, MD, FAAFP, 500 University Dr., Hershey, PA 17033 (email: kclebak@pennstatehealth.psu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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2. Graham GF. Cryosurgery. Clin Plast Surg. 1993;20(1):131–147.

3. Andrews MD. Cryosurgery for common skin conditions. Am Fam Physician. 2004;69(10):2365–2372. Accessed October 31, 2019. https://www.aafp.org/afp/2004/0515/p2365.html

4. Kuflik EG. Cryosurgery updated. J Am Acad Dermatol. 1994;31(6):925–944.

5. Dawber R. Cryosurgery: unapproved uses, dosages, or indications. Clin Dermatol. 2002;20(5):563–570.

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7. Simon CA. A simple and accurate cryosurgical tool for the treatment of benign skin lesions: the “hard tail” dipstick. J Dermatol Surg Oncol. 1986;12(7):680–682.

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10. Canpolat F, Cemil BC, Eskioğlu F. Liquid nitrogen cryothearpy of plantar verrucae: cryoblast is more effective than the cryospray. Eur J Dermatol. 2008;18(3):341–342.

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12. Thai KE, Sinclair RD. Cryosurgery of benign skin lesions. Australas J Dermatol. 1999;40(4):175–184.

13. Cooper C. Cryotherapy in general practice [published correction appears in Practitioner. 2001;245(1629):1031]. Practitioner. 2001;245(1628):954–956.

14. Jennings L, Schmults CD. Management of high-risk cutaneous squamous cell carcinoma. J Clin Aesthet Dermatol. 2010;3(4):39–48.

15. Puig S, Berrocal A. Management of high-risk and advanced basal cell carcinoma. Clin Transl Oncol. 2015;17(7):497–503.

16. Torre D. Cosmetic aspects of cryosurgery. Cutis. 1976;17(3):422.

17. Lansbury L, Bath-Hextall F, Perkins W, et al. Interventions for non-metastatic squamous cell carcinoma of the skin: systematic review and pooled analysis of observational studies. BMJ. 2013;347:f6153.

18. Thai KE, Fergin P, Freeman M, et al. A prospective study of the use of cryosurgery for the treatment of actinic keratoses. Int J Dermatol. 2004;43(9):687–692.

19. Gupta AK, Paquet M, Villanueva E, et al. Interventions for actinic keratoses. Cochrane Database Syst Rev. 2012;(12):CD004415.

20. Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4(4):273–293.

21. Kwok CS, Gibbs S, Bennett C, et al. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2012;(9):CD001781.

22. Cockayne S, Hewitt C, Hicks K, et al.; EVerT Team. Cryotherapy versus salicylic acid for the treatment of plantar warts (verrucae): a randomised controlled trial. BMJ. 2011;342:d3271.

23. Cook DK, Georgouras K. Complications of cutaneous cryotherapy. Med J Aust. 1994;161(3):210–213.

24. Drake LA, Ceilley RI, Cornelison RL, et al.; Committee on Guidelines of Care; Task Force on Cryosurgery. Guidelines of care for cryosurgery. J Am Acad Dermatol. 1994;31(4):648–653.

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