Cryosurgery of verruca vulgaris:

What is the technic to freeze efficiently?Pearls Presentation

Herzl FMPCMay 25, 2011David St-Sauveur, R1

My practice-based clinical question

•P: When the patients in the setting of my family medicine practice have a common wart on their soles or on their hands

•I: what technics of cryosurgery should I use

•C: and what technics should I not use

•O: regarding the best clinical outcome?

What triggered this question?

• 26 years old men, foreign student from France

• visit in the Derm department, May 10, 2011, the first day of my rotation in this department

• coming with multiple verruca vulgaris on hands and soles present X ~ 1 year

• already tried a «spray» in pharmacy from Dr. Scholl's® that did not help at all (ingredients: Dimethyl Ether and Propane)

• [Cutaneous cryosurgery in family medicine: dimethyl ether-propane spray versus liquid nitrogen], [Article in Spanish], Caballero Martínez F, Plaza Nohales C, Pérez Canal C, Lucena Martín MJ, Holgado Catalán M, Olivera Cañadas G.

Source

Unidad Docente de Medicina Familiar, Insalud Area 6 de Madrid.

• CONCLUSIONS:

No clinically relevant differences between the efficacy, tolerance and safety of the two cryogenic agents used in primary care were found. The low freezing of DMEP was sufficient for the cryotherapy of benign lesions.

Physical exam

Article ID: ebm00276 (013.030)© Duodecim Medical Publications Ltd

Physical exam

Article ID: ebm00276 (013.030)© Duodecim Medical Publications Ltd

Dx

• Verruca vulgaris

• The diagnosis of a wart is clinically confirmed by point haemorrhages caused by cutting the wart horizontally with a scalpel or paring it.

How I did my research on the

net•Essential Evidence Plus

•using the word «cryosurgery»

•Pubmed

•using the words «cryosurgery» and «common warts» only with the MeSH search bar.

•and using the words «cryosurgery» , «technique» and «common wart» with the MeSH search bar thereafter.

Papers kept

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

Br J Dermatol. 2001 May;144(5):1006-9.

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud.Ahmed I, Agarwal S, Ilchyshyn A, Charles-Holmes S, Berth-Jones J.Source

Department of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K.

Cryosurgery of Skin Lesions

Essential Evidence

Last Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc.

Cryosurgery for common skin lesionsTreatment in family physicians' officesStephen J. Wetmore, MD, Msc, ccFPCanadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999

Br J Dermatol. 2001 May;144(5):1006-9.

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud.Ahmed I, Agarwal S, Ilchyshyn A, Charles-Holmes S, Berth-Jones J.SourceDepartment of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K.

• Study design: Prospective study

• on their first visit, the patients had a consultation with the dermatologist and those with a clinical dx of common wart were allocated to have liquid nitrogen applied either by spray or by cotton-wool bud

• the patients were treated every 2 weeks for 3 months in nurse-practitioner-led wart clinics

• Setting: patients referred by general practitioners of U.K. to the dermatology departments of two hospitals

• N = 363

• Mean age 21 (range 3-75)

• 188 males; 175 females

• Mean number of warts: 5 on hands and feet

• Mean duration of warts was 98 weeks (range 2-936 weeks)

Br J Dermatol. 2001 May;144(5):1006-9.

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud.Ahmed I, Agarwal S, Ilchyshyn A, Charles-Holmes S, Berth-Jones J.SourceDepartment of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K.

• Treatment:

• cryotherapy with the spray gun was done with a «B» nozzle. The spray gun was held perpendicular to the wart at a distance of 1-2 cm.The wart was sprayed until the ice-ball formation had spread from the centre to include the edge of the wart and a 2-mm margin. It was then allowed to thaw. Plantar warts were treated with a double freeze-thaw cycle with complete thawing of the wart between the cycles.

• Liquid nitrogen contained in an open flask was used to treat the warts with a CWB. These buds were made of loosely woven cotton wool on orange sticks. As with the spray method, warts were frozen until ice-ball formation had spread from the centre to include a 2-mm margin around the wart.

Br J Dermatol. 2001 May;144(5):1006-9.

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud.Ahmed I, Agarwal S, Ilchyshyn A, Charles-Holmes S, Berth-Jones J.SourceDepartment of Dermatology, University Hospitals, Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, U.K.

•Results:• Table 2. Cure rates

• Cryotherapy with liquid nitrogen for hand and foot warts was equally effective when applied with a cotton wool bud or by means of a spray (p = 0,8)

Cured Not cured Defaulted

CWB group (n à 205) 55 (47%) 63 87

Cryo-spraygroup (n à 158)

39 (44%) 50 69

devices

• cotton-tip applicator, liquid nitrogen spray, cryoprobe

• the cotton-tipped dipstick method of liquid nitrogen application has been popular in the management of common benign lesion. However, this method is being supplanted by liquid nitrogen spray techniques, since it is easy to use and similar technics can be employed to manage benign, premalignant, and malignant lesions.

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

spray methods

•the timed-spot freeze technic

•the rotatory or spiral pattern

•paintbrush method

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

The timed-spot freeze technic

• *allows greater standardization of liquid nitrogen delivery.

• **Use of this technique maximizes the ability to destroy a lesion with minimal morbidity.

• technique:

• the nozzle of the spray gun is positioned 1 to 1.5 cm from the skin surface and aimed at the center of the target lesion

• The spray gun trigger is depressed, and liquid nitrogen is sprayed until an ice field (or ice ball) encompasses the lesion and the desired margin

• Margins for most benign lesions can extend as little as 1 to 2 mm beyond the visible pathologic border

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

The rotatory or spiral pattern &Paintbrush method

• These techniques can be useful for treating larger benign lesions.

• They are not well standardized for ensuring the temperatures that are required for the destruction of malignant lesions

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

American Family PhysiciansMay 15, 2004 Table of Contents

Cryosurgery for Common Skin ConditionsMark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

Recommended cryosurgical techniques

type techniquefreeze time

(seconds)

number of freeze-thaw cycle

margins(mm)

number of tx

sessions

intervals(weeks)

common wart

open spray 10 1 2 3 4

Cryosurgery of Skin LesionsEssential EvidenceLast Updated on 2009-05-25 © 2009 John Wiley & Sons, Inc.

• Cryotherapy with liquid nitrogen spray

• Fill a spray gun with liquid nitrogen and replace the lid to allow pressure to build up.

• Hold the desired tip size of the gun 1 cm to 2 cm from the lesion.

• Depress trigger and freeze the lesion to the desired freeze margin.

• Use a zigzag or rotary motion to limit the depth of freeze for superficial lesions (eg, actinic keratoses, lentigos, or flat warts).

• Repeat after the lesion has thawed.

• Typical freeze margins

• No informations given for the duration on the cryosurgery.

typical freeze margins for cryotherapy

type of lesion margins in mm

warts 2 mm - 3 mm, based on size/thickness

Cryosurgery for common skin lesionsTreatment in family physicians' officesStephen J. Wetmore, MD, Msc, ccFP

Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999

freeze time for various benign skin lesions

Lesionsfreeze time (seconds)

liquid nitrogennitrous oxide (seconds) comments

warts:Non plantar

10-20 up to 60

Plantar 30-60 40 after paringpare plantar warts first; use double freeze-thaw

cycle

Periungal up to 45

Cryosurgery for common skin lesionsTreatment in family physicians' officesStephen J. Wetmore, MD, Msc, ccFP

Canadian Family Physician . Le Medecin de famille canadien * VOL45: APRIL * AVRIL 1999

• «Spray is applied from 1 to 2 cm above the lesion»

• «Successful treatment depends on the lesion's being included in the lethal freeze zone. For this reason, the lateral spread of freeze should extend at least 2 mm beyond the margins of benign lesions and 5mm beyond the margins of malignant lesions.»

American Family Physicians: Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

Cryosurgery in dermatologyEuropean Journal of Dermatology. Volume 8, Number 7, 466-74, October - November 1998, Formation Médicale Continue

My practice decision

•using the spray gun... since it is easy to use and similar technics can be employed to manage benign, premalignant, and malignant lesions.

• Using it perpendicular to the warts at a distance of 1-1,5 cm aimed at the center of the target lesion.

• Using the the timed-spot freeze technic since it is better known than the rotatory and paintbrush methods and so better standardized.

My practice decision

Recommended cryosurgical techniques

type techniquefreeze time

(seconds)

number of freeze-thaw cycle

margins(mm)

number of tx

sessions

intervals(weeks)

common wart

open spray 10 1 2 3 4

American Family PhysiciansMay 15, 2004 Table of Contents

Cryosurgery for Common Skin Conditions

Mark D. Andrews, M.D., Wake Forest University School of Medicine, Winston-Salem, North Carolina

Am Fam Physician. 2004 May 15;69(10):2365-2372.

...and I would do 2 cycles of freeze-thaw for plantar warts.