18 Dermatologic Surgery S KIN & ALLERGY N EWS • December 2006 Intralesional Cryosurgery Good for Deep Lesions

Procedure reduced scar hardness, elevation, and curred during or af- ter the procedure redness; no recurrences were reported at 18 months. was easily man- aged. No active BY SHARON WORCESTER caine, and the sterile cryoprobe was forced bleeding, infection, Southeast Bureau into the long axis of the scar, with the or adverse reactions sharp tip of the needle penetrating the dis- such as hypopig- HAI

R HODES, GREECE — A new intrale- tal edge of the scar. mentation oc- -S AR sional cryosurgery technique for targeting Upon activation of the cryogun, the curred, he noted. H dermal skin lesions is safe and effective for cryogen froze the keloids within 5-30 min- The patients, sev- the treatment of keloids and hypertrophic utes, depending on scar volume, as iceballs en women and two ARON . Y R scars, Dr. Christos Zouboulis reported at appeared at each penetrating point of the men aged 18-55 D the 15th Congress of the European Acad- cryoneedle and gradually spread toward years, had a total of emy of Dermatology and one another. When the ice- 10 keloids of 6 Venereology. The lack of balls met, indicating com- months’ to 6 years’ The technique is a mod- plete freezing of the keloid, duration. The

hypopigmentation HOTOS COURTESY ified version of one first the cryogun was disengaged, keloids, which re- P reported in 1993 and is per- suggests this and the cryoprobe was al- sulted from pierc- Auricular keloids are shown at baseline (left) and after the formed using a novel in- technique might lowed to defrost for 1-2 min- ings in 9 of 10 cas- intralesional cryosurgery technique. tralesional cryoprobe (Et- utes before being carefully es, and from a gar Group International be useful in withdrawn. laceration in 1 case, had failed to respond adjacent areas of the central cryolesion, re- Ltd., Israel) invented by Dr. patients with Treatment resulted in an to excision, laser surgery, surface vealing a limited, demarcated, irreversible Yaron Har-Shai of Berlin, average 67% reduction in cryosurgery, intralesional corticosteroid cell injury—suggests this technique might Germany, and his associ- pigmented skin, scar volume at 6 months, injections, and/or silicone ointment. The be particularly useful in patients with ates. The probe, which is who have a high which was maintained for up findings were reported earlier this year by black or pigmented skin, who have a high approved by the U.S. Food to 18 months after a single Dr. Har-Shai, Dr. Zouboulis, and their as- prevalence of keloids, Dr. Zouboulis not- and Drug Administration, prevalence of treatment. The average pre- sociates (Wound Rep. Regen. 2006;14:18- ed, adding that this technique and tech- has an elongated, double- keloids. treatment scar volume was 27). nology can be applied to scars of various lumen, uninsulated needle 2.89 cm3, compared with an Histologic evaluation and studies of shapes and contours at the ear helix and with a safety cryogen vent and a sharp-cut- average posttreatment volume of 1.17 swine tissue following ex vivo intralesion- lobule, as well as in other areas of the ting, sealed, distal tip designed to easily cm3, said Dr. Zouboulis of Dessau (Ger- al cryosurgery—conducted as part of the body, as demonstrated in this and other penetrate hard and dense dermal lesions many) Medical Center. same study in an effort to explain the studies. such as keloids and hypertrophic scars. Patients also had significant reductions mechanism of action of the cryoprobe— In fact, the technology was developed In a pilot study of nine patients with re- in scar hardness, scar elevation, and red- showed that the technique destroys the for and will be studied for other indica- calcitrant auricular keloids, the proximal ness (average pre- and posttreatment core of the scar with only small effects on tions involving deep skin lesions; keloids end of the probe was attached to an adap- scores of 2.9 vs. 0.50, 3.0 vs. 1.0, and 2.9 surface cells, including melanocytes. The served as a “nondangerous proving prin- tor, which was connected to a standard vs. 0.8, respectively). Subjective complaints cryodamage caused by the technique is ciple” for efficacy, he explained. “cryogun” cryogen source. The cryogun were also reduced following treatment, self-limited, and complete cell death is “The major advantage of the intrale- was filled with liquid nitrogen about 15 with reductions seen in itching, pain, and identified in the central cryolesions im- sional cryoprobe to destroy the deeply lo- minutes before the procedure to allow tenderness (average pre- and posttreat- mediately following treatment; this sug- calized target tissue with minimal effect on adequate pressure to build up. ment scores of 2.5 vs. 1.19, 2.0 vs. 0.3, and gests that direct cryothermic injury is the the superficial skin layers may have a sig- The patients were placed in the supine 2.3 vs. 0.4, respectively). There were no primary mechanism of action, the inves- nificant importance in the future in the position, and the keloid surface was scar recurrences at 18 months’ follow-up. tigators explained. clinical application of cryosurgery not cleaned, disinfected, and draped. The area The treatment was generally well tol- The lack of hypopigmentation in this only in the treatment of keloids but also to be penetrated with the cryoprobe was erated, Dr. Zouboulis said. study—which might be explained by the of other deeply localized skin lesions and intralesionally anesthetized with 1% lido- Any mild pain or discomfort that oc- minimal histologic changes in superficial tumors,” he concluded. ■ Combo Topical Therapy, Cryosurgery May Beat Excision

BY SHARON WORCESTER Southeast Bureau

R HODES, GREECE — Combining topical im- munomodulatory therapy or topical chemotherapy with ASQUALI cryosurgery provides an excellent alternative to exci- P sional treatment for many skin malignancies, Dr. Paola Pasquali said at the 15th Congress of the European AOLA . P R

Academy of Dermatology and Venereology. D Cryosurgery itself represents an excellent option for many skin malignancies, including most basal cell carci- OURTESY nomas. Exceptions include morpheaform, metatypical, C and neurotropic basal cell carcinomas, for which Mohs HOTOS surgery is preferable. Cryosurgery is also beneficial for P well-differentiated squamous cell carcinomas and lentigo This female patient had a hypertrophic actinic Improvement was evident after cryosurgery of the maligna, she said. keratosis that was associated with a squamous cell nodular lesion and treatment with imiquimod on the The use of the immune response modifier imiquimod carcinoma and severe actinic damage. rest of the patient’s damaged skin. before any surgical intervention can improve local im- mune response and reduce treatment areas. Cryosurgery weeks, followed by cryotherapy for remaining lesions. orouracil can also be used along with cryosurgery in can then be used to treat areas that failed to respond, said This reduces the need for surgical treatment and pro- some patients, such as those with actinic keratoses or Dr. Pasquali, a dermatologist in private practice in Cara- vides a better cosmetic outcome, she said. Bowen’s disease. cas, Venezuela. For nodular basal cell carcinomas, biopsy and curettage As with imiquimod, the topical treatment is used to re- This approach is particularly useful in patients with is performed, and the lesion is allowed to heal before im- duce the number and size of lesions and the remaining severe sun damage with multiple actinic keratoses or su- iquimod treatment is initiated and cryosurgery is used to lesions are treated with cryosurgery. perficial basal cell carcinomas, she said, noting that she treat remaining lesions. These combinations also are useful for palliation in pa- has her patients use imiquimod 5 days a week for 6 Topical chemotherapy with the antimetabolite 5-flu- tients with large tumors, Dr. Pasquali noted. ■