STD clinics dealing with genital warts and other skin lesions require access to modalities of dermatological treatment which furnish cosmetically satisfactory results.
Cryosurgery is a non-invasive modality of treatment via the application of liquid nitrogen (or other freezing refrigerants) to the skin to induce necrosis to the offending lesion. This is done in a controlled environment through the hands of an experienced clinician who is trained to visually analyze and deduce the duration and amount of freezing required to bring about a localized frostbite sufficient to cause inflammation, swelling, and eventual necrosis and death of the lesion being removed or treated.
Cryosurgery is not the only modality of treatment for various lesions like keloids, genital warts and superficial skin growths, but it furnishes a rapid, accessible and effective means – under the hands of an experienced operator – to remove an offending lesion with relatively less time and with comparatively better cosmetic results. Other options might include surgery and laser therapy, both of which might involve higher cost, downtime, and degree of invasiveness.
Lesions for Cryotherapy
In HIV STD clinics in Singapore, there are many lesions of the skin that are suitable for cryosurgical removal and treatment. Such lesions include:
- Keloids and hypertrophic scars
- Plantar and palmar warts
- Genital warts
- Benign skin growths like skin tags, pearly penile papules, molluscum contagiosum, pyogenic granulomas, seborrhoeic keratosis, and solar lentigines
- Premalignant skin lesions such as actinic keratoses and Bowen’s disease (biopsy needed)
- Malignant skin growths
Cryosurgery is best suited for the treatment of epidermal lesions. Results from cryosurgery are very dependent on the experience of the clinician performing the procedure. The application of liquid nitrogen is apparently simple, but the amount and depth of freezing required is not easily gauged. It takes a good eye trained with years of application to know how long, how much, how wide, and how deep to apply the cryosurgical agent.
There was a case where the over-zealous application of liquid nitrogen by an inexperienced operator for genital warts created deep ulcerations on the vulnerable portion of my patient’s manhood. He consulted me for treatment of his ulcers and the ineffectively treated genital warts. It cannot be over-emphasized that cryosurgery requires practice and experience for cosmetically satisfactory results. Adequate training would help to obviate complications due to this procedure.
Inappropriate Lesions for Cryosurgery
Physicians practicing in HIV STD testing clinics in Singapore should exercise caution with this modality of treatment. Cryosurgery should be withheld if the lesion is suspected to be invasive or malignant, such as a malignant melanoma. Generally, histological confirmation of the diagnosis should be performed for these cancerous lesions and growths. Some lesions are recommended for excisional biopsy and surgery as the standard of care.
Cryosurgery usually should not be used to treat infiltrative, micro-nodular or recurrent basal cell carcinomas. Poorly differentiated or recurrent squamous cell carcinomas should also not be treated with cryosurgery.
Malignant lesions in areas such as pre-auricular or nasolabial regions are known to have high rates of recurrence after cryosurgery. In such cases, surgery with histo-pathology allows the clinician to better manage the cases.
The clinician must also be careful when using cryosurgery on hair-bearing sites, such as the scalp. Permanent hair loss has been reported, and longer freezing times in these regions are not appropriate. Also, longer freezing times in Fitzpatrck skin types 4 and 5 can produce pigmentation disorders such as hypopigmentation and hyperpigmentation, and may be cosmetically undesirable. Sometimes, a small, test area of skin is treated to see how the patient responds to cryosurgery or cryotherapy prior to the treatment of larger areas.
Elderly patients with poor circulation in the lower limbs must be treated with caution, as there is increased risk of tissue breakdown and long healing times.
Advantages of Cryosurgery
The availability of cryosurgery in an office practice is both a convenience to the patient and the family physician. The patient is often glad that they do not need to book an appointment for elective surgery, as cryosurgery can often be performed within the same consultation.
In the hands of an experienced operator, the immediate postoperative complications are usually minimal, besides the usual localized discomfort and inflammatory symptoms expected of freezing a lesion. Compared to surgical excision, there are no sutures to be removed, less risk of wound infection requiring antibiotics, and no downtime off work.
Patients with a higher preponderance of developing hypertrophic scarring or keloid scarring would usually be advised to undergo cryosurgery instead of excisional surgery as there is an inherent risk of scarring post-excision.
Hence, cryosurgery is an accessible and relatively safe modality for the physician practicing in HIV PEP clinics in Singapore.
Side Effects and Complications of Cryosurgery
Complications from cryosurgery are very unusual especially in experienced hands. Most patients complain of mild discomfort in the area treated. This resolves rather quickly, as most HIV STD clinics would testify.
In the early stages immediately after freezing, there may be localized pain and discomfort, occasional blister formation (including hemorrhagic blisters), edema, or weepy discharge. Very rarely would there be mild infection, hemorrhage from the wound, pyogenic granuloma, or delayed healing in diabetics or individuals with poor circulation.
In persons with darker skin, there might be hypopigmentation. Other complications like milia, scarring or alopecia are very uncommon.
Some Inconveniences of Cryosurgery in an Office Practice
One of the obvious inconveniences of doing cryosurgery is the storage and transport of refrigerants. Thankfully, currently designed dewars are able to store liquid nitrogen for appreciably longer periods of time, thereby avoiding the need for frequent refills. Liquid nitrogen evaporates rapidly, and practices that do not perform cryosurgery often might find it relatively costly to maintain this service for their patients.
It must be emphasized that lesions suitable for cryotherapy must be accurately diagnosed, as cryosurgical treatment is a destructive process and leaves no tissue for histo-pathology. Clinicians who are not confident of the diagnoses should not freeze lesions blindly, but do a proper biopsy and send the specimen for histological diagnosis.
Conclusion
Our HIV PEP Singapore clinic provides cryosurgery services for various skin problems, such as keloid scars and genital warts. Some lesions such as keloid scarring may require a multimodality approach to effectively control and manage the lesion. Our board accredited Family Physician would review your case and provide you with the best treatment approach. We also furnish up-to-date HIV and STD testing and screening according to the latest guidelines and recommendations.
