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INTRODUCTION

Cryosurgery is among the most powerful and efficient tools used in dermatology. This minimally invasive and cost-effective procedure is valuable for the treatment of many benign, premalignant and certain superficial malignant lesions, and is an alternative for patients who are bedridden, have blood-borne illnesses, or simply do not wish to undergo a surgical excision. As with any procedure, the risks and benefits must be properly explained. Cryosurgery has truly stood the test of time and with proper training may be used to treat a wide variety of cutaneous lesions with ease.

HISTORY

Cryosurgery is one of the oldest and most versatile procedures in dermatology. The medical use of cold dates back over 4,000 years, when ancient Egyptians used it as a local anesthetic to minimize the pain of trauma and decrease inflammation. Baron Dominique Larrey, the military surgeon of Napoleon’s army, used ice and snow to pretreat injured limbs before amputation. In 1851, James Arnott of London pioneered a local analgesic using ice and saline for palliative treatment of cancerous tumors in terminally ill patients. As the first to achieve temperatures around −24°C, Arnott is often described as the father of “modern” cryosurgery.1 In 1899, Campbell White, a New York dermatologist, became the first to successfully treat warts, nevi, keratoses, and skin cancers with a cotton-tipped applicator dipped into liquefied air. In 1907, another dermatologist, H. H. Whitehouse, engineered the first spray device delivering cryogen.2 Soon thereafter, W. A. Pusey promoted carbon dioxide to treat acne and nevi.3,4 Liquid nitrogen (LN) replaced carbon dioxide as the primary cryogen in 1948. During this time, LN was applied to lesions using a cotton-wool swab. In the mid-1960s with the help of Whitehouse’s ideas, Setrag Zacarian and Douglas Torre made cryogen delivery more efficient. Zacarian designed the method of indirectly administrating LN by cooling copper cylinders while Torre developed a reliable LN spraying system.5 Around the same time, Irving S. Cooper, a neurosurgeon, found a way to bring LN to a controlled temperature of −195°C, which is the temperature we use in dermatology today. In 1968, Michael Bryne developed the first commercially available handheld cryosurgical device.6,7

BASIC PRINCIPLES

Cryosurgery is unique because it provides a safe, effective, and economically feasible method of treating a variety of dermatological conditions. The subzero temperatures which it achieves cause cellular damage and death through heat extraction. The cellular damage itself occurs through direct injury, vascular stasis, apoptosis, and immunologic effects.

Freezing temperatures cause direct injury by creating an osmotic gradient. Crystallization outside the cells causes water to rush outward, which leads to internal dehydration, organelle damage, cell membrane and cytoskeleton changes which compromise the integrity of the cell. Additional freezing creates internal crystallization, which causes cell lysis. During the thawing process the osmotic gradient reverses as ice crystals reorganize within the cell; this leads to further destruction ...

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