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Can Cryo stimulate new VP's?

Discussion in 'General Issues and Discussion Forum' started by Princess, Sep 11, 2008.

  1. Princess

    Princess Active Member

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    I've been doing Cryosurgery for VP's for 7 years yet today - 2 of my patients have presented with additional satellite VP's - one had a count of 15!
    Can Cryo stimulate these satellites or is it a sign that the Vp's under threat and trying to get a hold somwhere else?

    Should I continue to treat these patients with Cryo or try some other method.

    Any advice greatly appreciated!
  2. Brummy Pod

    Brummy Pod Active Member

    I used to use low level laser on VPs. Worst mistake that I ever made in PP. Anyway, after 3 visits of using laser on a resistant lesion, another one appeared, and that was resistant to treatment. The patient was not happy with me, as it was a bit of a coincidence that another one had appeared.

    Now, I do not even think of using low level laser on a VP. There is very little evidence base that it works for VPs. Very few practitioners think that it does anything for VPs.

    I certainly would not want to be in front of the HPC having used solely laser on a VP!
  3. Adrian Misseri

    Adrian Misseri Active Member

    I'm finding weekly heavy debridement and aplication of phenol to be quite useful with those stubborn ones, but at the end of the day it's the bodies aown immune system that we need to kick in and kill it itself?
  4. Johnpod

    Johnpod Active Member

    One possible mechanism is that cryo might damage surrounding cells so that they can no longer produce interferon to limit the spread.

    Damaged cells have little or no resistance and are often macerated - maceration of tissue is often a precursor to viral infection.

    A recent Cochrane review recognised that cryo is only successful in 40% of cases.

    I use cryo as an adjunct to other modalities or to break the deadlock when one modality alone is proving inadequate (because cells damaged by one agent can put up less resistance and will be killed by the other).

    Hope this helps!
  5. Primary reason for lack of success in cryosurgery is poor technique combined with a lack of understanding of the tissue response to exposure from the cryogen. One of the most common complications with cryosurgery is the Korner response which occurs when a post operative bullae forms and is not adequately debrided and removed. New lesions will then appear around the margins of the blister within 6-8 weeks.

    I have already uploaded a paper on podiatric cryosurgery to Podiatry Arena - will do so again on this thread later today.

    From British Journal of Podiatric Medicine 1990

    Podiatric Cryosurgery

    The application of a cryogen or refrigerant to remove body heat in an effort to destroy diseased or malignant tissue has been utilised in medicine for over a century. However, only in the last thirty years has our knowledge of cellular pathogenesis to freezing made cryosurgery an exact science and a commonly found modality in the treatment of benign, precancerous and cancerous tumours.

    Cryosurgery has been popular with chiropodists and podiatrists for a number of years in various forms, namely CO2 dry ice, nitrous oxide pressurised gas systems, and, more recently, with liquid nitrogen systems. The degree of success has varied markedly, depending on the type or system or cryogen used, and, also, because of lack of adequate literature and training available to practitioners, on the most efficient methodologies of incorporating this valuable form of treatment into their clinical regimes. In addition, the majority of cryosurgical units that have been available to podiatrists have generally produced inadequate freezing velocities, or temperatures required to destroy tissue located in the foot. Liquid nitrogen is the only coolant for the effective eradication of podiatric complaints such as verrucae and porokeratosis plantaris discreta. Until recently, the only type of equipment available to practitioners has been the nitrous oxide and carbon dioxide CSUs, and with an operating temperature of -89o this has proved ineffective for plantar tissue which is both thicker and lower in moisture content than, say, epiethelial tissue in the treatment of leucoplakia or in cervical tumours.

    The past few years has seen a great improvement in the technology available for liquid nitrogen cryosurgery, and, conversely, a notable advancement in the treatment of applicable podiatric conditions. As always, it is essential to understand the effects of the application of liquid nitrogen to a lesion, and, as such, there follows a summary on the pathogenesis of the cryolesion followed by techniques employed in podiatric applications.

    Freezing is a physical phenomenon for living tissue or cells, and the withdrawal of heat from this living tissue is the basis for cryosurgery. Freezing represents nothing more than the removal of pure water from solution and its isolation into biologically inert foreign bodies, the ice crystals. All the biochemical, physiologic and anatomical sequelae of freezing are directly or indirectly the consequences of this single physical event. Freezing converts water into ice in a process of crystallisation through dehydration. The size of the crystals and the site of development, whether intracellular or extracellular, are governed by the boiling point of the refrigerant and the rate of freeze. The faster the freeze, the greater the tendency for the formation of microcrystals, which are more lethal than larger crystals. The heat generated during the cooling process with the conversion of water to ice is referred to as the latent heat of fusion. As the water is turned to ice, one can measure the production of heat, equivalent to 80 calories per gram of water. No matter how prolonged or profound the freeze, a small percentage of water within the cells will remain frozen. This is referred to as bound water.

    As tissue is frozen, the iceball within the tissue forms into a hemispherical shape. The depth of freeze approximates the radius of the flat surface of the frozen hemisphere. The ice front close to the cryoprobe is much colder than the margins of the iceball itself. This is referred to as the thermal gradient. The development of the iceball and subsequent evolution of the cryolesion is influenced by these factors:

    1. The thermal conductivity of the tissue.
    2. Tissue blood perfusion tates.
    3. The specific heat of the surrounding tissue.

    One cannot freeze indefinitely, as an equilibrium of temperature transfer is reached between the cryoprobe and the surrounding tissue. The iceball advances until a balance is maintained between the cryogen and the underlying rate of blood flow within the tissue. The development of the cryolesion, and its thermal gradient resulting in the cryonecrotic state of the frozen tissue, is dependent on a number of important factors:

    1. The boiling temperature of the cryogen.
    2. The volume and depth of the tissue to be frozen.
    3. The probe tip size.
    4. The thermal conductivity of the tissue to be frozen.
    5. The cellular composition of the tissue.
    6. The rate of underlying blood flow within the tissue.
    7. The velocity or rate of cooling.

    Cryonecrosis: Cellular response to freezing

    There are several distinct mechanisms whereby freezing causes cellular injury, and within the iceball caused by the cryoprobe application, all of these mechanisms exist. Tissues will freeze at -2.2oC, though a number of factors must coexist to achieve cryonecrosis. After all, many body organs are subjected to extreme temperature when undergoing transplant surgery, and function with no signs of cellular injury after thawing. As stated, the fundamental change during freezing is the conversion of fluid into ice within a cell and its interspaces. The more rapid is this conversion, the greater the degree of hypothermia, and, conversely, the more deleterious the effect on living cells. During the thaw phase, the more rapid this is, the greater the chance of survival, whereas a slow thaw induces a high kill ratio. The changes that take place within a cell subject to freezing are:

    1. Development of extracellular ice formation.
    2. Development of intracellular ice formation.
    3. Abnormal concentration of electrolytes.
    4. Eventual crystallisation of the electrolytes.
    5. Cell dehydration.
    6. Thermal shock.
    7. Denaturation of lipoprotein complexes.

    All of these changes are complex and depend on a number of factors. For example, slow cooling produces large crystals which are not as lethal as the microcrystals that occur with rapid freezing. Remember that freezing temperatures are at varied thermal gradients, and that the velocity of freezing cells closest to the cryoprobe is much greater than those at the periphery of the iceball.

    Immunological effects

    Cryosurgery, in comparison to other forms of therapy, permits the controlled cryogenic destruction of lesions, concomitantly possessing the potential to augment or induce host resistance to the lesion, thus potentiating cryoimmunisation and cryoimmunotherapy. Evidence shows that cell destruction by freezing is accompanied by antigen formation through the liberation of lipoproteins from the cell membrane. This response is tissue specific, and this may explain why, in HPV infection, good cryosurgery technique is so effective, whereas in cauterising surgery, such as electrodesiccation or with CO2 laser surgery, the process tends to denature the protein functions and the response is lost. With many instances of multiple lesions regressing after an initial treatment of one verruca, it would suggest that the antibody response is of vital importance.

    Effect on connective tissue

    An advance of cryosurgery often cited is that of minimal, if any, scar formation postoperatively. Research has shown that the collagen fibre network of the dermis remains largely unaffected by the standard liquid nitrogen freeze times employed by a clinician. The presence of this collagen fibre network enables the skin architecture to return to more or less normal after surgery. However, it has been established that the fibre network loses its structural integrity in the coagulation of protein which occurs after thermal burning, which would explain the incidence of scar formation following electrodesiccation or laser surgery.

    Cryosurgical technique in clinical practice

    Cryosurgery can be employed on the vast majority of patients, and receives a high patient acceptance. In almost all cases, application and treatment can be completed in one visit, and the patient is ambulatory after surgery. In the majority of cases, no anaesthesia need be applied, though with patients who display a low pain threshold, or where the lesion is on a painful site such as a neurovascular heloma, analgesia can be administered in several ways:

    1. Administration of a subcutaneous local anaesthetic such as 2% lignocaine or 4% citanest. With liquid nitrogen cryosurgery, this should not be an infiltration technique, but rather a regional anaesthesia such as posterior tibial block. Freezing of the local anaesthetic with infiltration methods can produce perilesional damage.

    2. Conscious sedation therapy utilising a controllable oxygen/nitrous oxide inhalational mix.

    3. High frequency electrotherapy anaesthesia such as H-Wave neurological stimulation.

    However, not every patient is a candidate for cryosurgery. A patient may present with a condition for which cryosurgery is indicated, but which has, by clinical judgement, progressed beyond the scope for which it would be effective. Conditions such as malignant melanoma or verrucous carcinoma are prime examples of this. In essence, this technique may be employed as a guideline when a patient presents at the surgery.

    1. Assessment and counselling of the patient
    The patient should be fully informed about the cryosurgical process and the postoperative course. An informative handout at the assessment visit will help to reassure any doubts. Clinical judgement will determine whether anaesthesia should be employed for the procedure, and, again, the patient’s suitability has to be considered.

    2. Evaluation of the freeze site
    Careful assessment of the area must be scheduled prior to treatment. Skin type, classification and site of the lesion, along with previous history, all have to be considered in depth. Plantar skin is the most difficult area of the body to freeze, given its thickness and relative dryness compared to epithelial lining such as the cervix or in the oral cavity. Patients with exceptionally dry skin may be advised to soak their feet prior to treatment, or, alternatively, the clinician may opt to apply a 25% salicylic acid preparation to the lesion three days prior to the cryosurgery. The type of lesion is also important. A large solitary HPV1 type of lesion, located on the plantar surface of the heel, may require three repeated freezes of up to 90s each during the visit, whereas a single plane wart located on dorsal skin may require one freeze of only 15s. There are no written rules for freeze times or cycles. Adequate assessment of the site, classification of the lesion, and suitable patient history, combined with operational experience should enable adequate management.

    3. Freezing of the target site
    With verrucae infections, the overlying hyperkeratosis is removed prior to application. It is advisable to mark on the skin an area around 4 mm beyond the margins of the lesion. In the initial stages this will enable to clinician to gauge the size of the iceball formation in comparison to the target tissue. This close monitoring will also prevent the most common cause of failure – under-freeze of the lesion. Selecting a probe tip similar in size to the lesion, a water-soluble gel is applied to the freeze site, the probe is place in position perpendicular to the tissue, and freezing is commenced. When the tissue iceball progresses to the 4 mm border, one can assume that the lesion is within the lethal zone for cryonecrosis. The employment of a water-soluble gel enhances the thermal transfer, and gives good adherence to the skin whilst the procedure is performed.

    4. Postoperative care
    A sterile gauze dressing should be applied after the procedure, and deflective padding is useful where the lesion is on a weight bearing area. The reaction of the tissue following cryosurgery will vary between patients. In some cases a haematoma may form fully within a 12-24 hour period, whereas in others, a small intradermal bulla may not be apparent for up to five days post-operatively. In general, one should schedule the follow-up visit some three to five days after treatment, being prepared to see the patient at short notice should a haematoma develop. There is much debate on the care of blister formation. Some clinicians prefer to leave the lesion in situ, and wait until the necrosed skin sloughs off after a period of time. Others will prefer to excise the lesion at the blister stage and then debride the base. Both methods have their merits, and individual choice and preference will ensue with experience. Healing time will vary depending on the size of the lesion treated and the general health of the patient. On average, complete granulation and healing will take place between ten and twenty one days following the procedure.

    Cryosurgical equipment

    There has been much development in the technology available to chiropodists and podiatrists utilising the modality of cryosurgery within their clinical regime over the past ten years. In general, equipment can be classified into three main categories:

    1. Closed probe Joule Thomson equipment, which encompasses the pressurised gas systems using carbon dioxide or nitrous oxide gas to expand rapidly within a restricted probe tip area. Such systems are largely ineffective for podiatric conditions due the slow cooling velocities and modest probe tip temperatures of, at best, -89oC. This combination results in low success rates for the management of plantar verrucae where probe tip temperatures of below -120oC should be attained, and where freezing velocities in excess of -200oC/minute are required.

    2. Direct cryogen application. The provision of liquid nitrogen spray guns operating at a pressure between 8psi and 30psi have allowed practitioners to incorporate, what is established, as the ideal cryogen into clinical practice. These units are relatively inexpensive at around £450,00 to £600.00 per unit and are simple to use and maintain. They are ideal when a superficial freeze is required such as in the treatment of mosaic warts or in the removal of tattoos, though as the cryogen comes into contact with the tissue, film boiling takes place and the cryogen is dissipated over the surrounding tissues causing a large superficial freeze. Due to the thickness of the plantar skin this type of application is seldom adequate to ensure sufficient depth of freeze and local formation of an iceball, giving only moderate success. The boiling of the cryogen on the skin can also be extremely painful and the clinician may also wish to consider the use of a local/regional anaesthetic.

    3. Closed probe liquid nitrogen systems. Recognised as the ultimate in design for cryosurgical applications, this system incorporates the benefits of indirect thermal transfer through a closed probe system with the ultra-low operating temperatures of liquid nitrogen at -196˚C. Giving a controlled freeze on the target tissue with freezing velocities of up to -720˚C per minute and a stable tip temperature of -190˚C, this is recognised to be the most efficient system for the eradication of the majority of podiatric conditions. Modern units incorporate an efficient electronic management system which monitors cryogen flow/pressure and is designed to deliver a constant tip temperature of -190˚C whilst economising the consumption of the cryogen by operating at a low pressure of between 1psi and 3psi. The more sophisticated models incorporate an automatic defrost control for easy removal from the freeze site thus eliminating unwarranted perilesional damage. More expensive than the direct spray units at between £1,500.00 and £2,900.00, their costs should be weighed against the success rate of around 96% eradication with a single procedure.


    In summary, it can be stated that cryosurgery has a number of benefits and advantages not shared by other operative procedures in the treatment of cutaneous anomalies presented in the podiatric sphere. It is a simple and safe procedure with a high clinical success rate and is also well tolerated by patients. With the advent of the latest generation of cryosurgical equipment we can anticipate predictable, desirable results for a variety of conditions where previous methodologies were costly and time consuming. However, it would be incorrect to assume that cryosurgery was a panacea for cutaneous skin conditions in podiatric practice. Common sense, combined with a comprehensive knowledge of diagnosis and pathophysiology is paramount for utilisation of today’s technology. In specialising and refining their cryosurgical technique, clinicians will have added a valuable ally to their armament in clinical practice.

    © Mark Russell 1990
    Last edited: Sep 12, 2008
  6. Princess

    Princess Active Member

    Thank you all for your replies.

    Mark, These new lesions have arisen within 2 weeks of first treatment of Cryosurgery and I always maximally debride the site.

    I have given one pt tea tree oil to apply daily in addition to Cryosurgey and another I have tried AgNO3. Time will tell!
  7. Tea Tree Oil - why?
  8. Princess

    Princess Active Member

    Hi Mark,
    The patient I have given tea tree oil to, is because she is an extremely image concious 13 year old, who is petrified that any of her friends will find out she has Vp. The staining of AgNO3 was unacceptable to her as it discolours the site. I wanted her to do something that she feels is helping them along, that she will do religiously.

    Not exactly scientific, but teenage girls aren't either! Tea tree oil is as good an alternative as any - and it smells nice!!
  9. Can you show me any published research that supports this statement?

    Also, if your patient is an image conscious teenager who has an issue with an AgNo3 eschar, how does she reconclie the appearance of plantar warts as opposed to healthy skin?

  10. Princess

    Princess Active Member

    No Mark, I can't.

    But go to any School of Podiatry or read any article or forum thread and tea tree oil is one of the methods discussed.

    As we are all aware - there is no guaranteed cure for Vps, yet we all have our preferred pathways either due to our training or experience.

    I have a number of patients that it has worked for in the past. Whether it worked or mere coincidence - who knows.
    I don't profess to know everything which is why I have posted - for advice.

    I also do not know how to instill logic into teenage girls even though I was once one - any advice on that is also gratefully recieved!
  11. Admin2

    Admin2 Administrator Staff Member

  12. Don ESWT

    Don ESWT Active Member

    I am a no nonsence person where are the VP's on this 13y old girl?

    Apply Mono and 66% Sal for 5 day. Remove wart - wound will heal in about 48 hours.

    You were not responsible for a further outbreak of VP's as they can take up to 18 months to manifest themselves

    To all,
    Don't pussy foot around with this virus. The old methods work. A person comes into your practice wanting to get rid of them. Tell them flat out that your Tx method and then let them decide. These warts can be 5mm to 50mm in diameter and 5mm to 15mm deep and no about of radical debridment is going to remove the virus without chemical intervention to macerate the surrounding tissue.

    You have not caused their problem and they will thank you when you have removed a couple of months later when they can compete in sports or ordinary walking activies pain free.

    What is one week of pain / discomfort when you will give them years of happy walking without warts.

    Don Scott
    Australia :santa::santa2:
  13. perrypod

    perrypod Active Member

    Is there any evidence to suggest that the human body actually rids itself of the virus? The lesions attributed to the virus may clear if treated or not, but as yet, I remain unconvinced either way as to if the virus has actually left the host or remains dormant and suppressed within the body. There are certainly patients who appear to have reoccuring bouts of warts. It will be interesting to see the degree of protection provided by the vaccination program designed to eradicate cervical cancer.
  14. Cameron

    Cameron Well-Known Member


    To answer your question it is unlikely cryotherapy will cause the spread of VPs - an unfortunate coincidence maybe but otherwise there is no direct association and satellite verrucae may be caused by other varieties of HP virus. I would concur with Mark provided the probe application is used properly and the original wart breaks down then the hope is the person would have immunity to that particular strain. However it is possible to be infected by another strain.

    In defence of tea tree oil (Australia's secret drug) it does seem to have a wide antimicrobial effect which may prove useful as a post op paint. I would suggest it as effective as povidone iodine with a more passive than active. There are several 'alternative' treatments (previously discussed) and some work and other less successful.

    Silver nitrate is a protein precipitant which causes an eschar to form - its application has nothing to do with treating a viral infection and was traditionally used only to discolour the skin for the clinical purpose of observing the skin's striations. Once a circumscribed lesion was no longer presented then this was taken as a visual sign the wart had gone. It was for the benefit of the clinician not the client. Sometimes AgNo3 is used as a keratolytic/plastic to dry out hyperkeratosis which again assists the clinician remove the excess keratin by minute dissection. The same technique can be used in removal of callus over the wart however this has nothing to do with clearing warts. The technique is popular and almost always used as a visual aid to encourage the patient to believe something is happening. But it is completely unecessary.

  15. Don ESWT

    Don ESWT Active Member

    I personally have not seen spontaneous disappearance of the virus. There may have been some form of tx and then over a period of time the bodies immune system has kicked in and deprived the virus of particulate matter to feed off.

    Dr. Ian Fraser is using Bovine wart virus to make the vaccine to treat cervical cancer.

    They may not be recurring bout :boxing: but still part of the intial infection still growing

    Don Scott
    Wollongong :santa:
  16. Princess

    Princess Active Member

    Hi all,
    Thank you for your replies, didn't see the patient for a couple of weeks and I bumped in to her mother who told me that they've now all gone!
    So, don't particularly know what was going on!

    Thanks again

  17. Don ESWT

    Don ESWT Active Member

    An interesting cast several years ago. A lady had LA injection into the centre of a VP on the PCA the GP then injected 6 more times 1 cm around the main VP. I was left to remove 7 VP.

    The moral is don't use LA anywhere within 1 cm of a VP and defenitely do not inject the surrounding area with the same needle & syringe.

    Also be aware that a VP can be 15mm deep

    Don Scott
  18. Johnpod

    Johnpod Active Member

    I agree with Don about pussy-footing around with VPs. They need decisive and concerted treatment. One of the reasons for many failures, I'm certain, is discontinuing treatment too soon or going at it too lightly.

    It seems to me that treatment with any modality below a certain threshold of potency will irritate and actually stimulate VPs. Effective treatments act above this threshold. This really comes down to any technique that will remove infected tissue at a faster rate than tissue can become infected by sideways/deeper transmission. The volume of the infected tissue can be considerable, and removal of this bulk indicates use of powerful keratolytics or deep and multiple freezing episodes. The cryo route always carries the risk of hypopigmentation and of creating neuropathic lesions.
  19. Hardly a robust RCT and given the erratic nature of HPV infection, I remain unconvinced. Back in the early 1980's I recall watching an Irish GP take a seven year old boy, who was suffering form multiple hand warts, down to the local abbatoir. He took the, by now, petrified lad to the killing pen and waited until a bullock was hoisted by the back legs after being stunned by the bolt. When the slaughterman cut the bullock's throat, the GP thrust the lad's hands into the torrent of blood and held them there until it stopped. I don't think I've seen such terror on a boy's face before - he had soiled himself and was shaking uncontrollably - an experiance that will remain with him for many years I suspect. Three weeks later the boy's warts had vanished. The GP claimed the technique had "good success" with multiple HPV infections. On balance I might prefer TTO but only because the nearest abbatoir is 25 miles away. In the meantime I'll leave TTO for ambulance crews...

    Last edited by a moderator: Sep 22, 2016
  20. blinda

    blinda MVP

    Loved it! “Out of the way I’m an aromatherapist:D!”

    Can`t stand the smell of it myself and I have seen enough cases of allergic contact dermatitis associated with use of TTO to discourage its use, which is often recommended as a `natural` topical antimicrobial.

    There is an interesting study in the Australasian Journal of Dermatology (Rutherford et al, 2007) which highlights the incidence of reactions to oxidized TTO as being relevant enough to warrant appropriate warnings on TTO products. It also states that the antimicrobial effect of TTO against bacteria, fungi and virus (herpes simplex only) has only been demonstrated in in vitro studies and that no clinical studies have revealed superiority of TTO over existing licensed pharmacological tx. Personally, I would rather utilise tx for VPs that have evidence base, and known complications, such as those included in the Cochrane review.

    That said, the reactive dermatitis associated with TTO could well be argued as the catalyst for VP resolution by means of the auto immune response.

    Another good read is Aberer, 2007. `Contact allergy and medicinal herbs`. This addresses the misconception that unlicensed herbal remedies are `harmless` or `gentle` drugs, as many contain active ingredients and/or toxic substances, which are not only capable of producing reactions such as contact dermatitis, anaphylaxis and photosensitivity, but can also adversely interact with other prescribed medication.

    Oh, and it also discusses reaction to marigold therapy!


    Rutherford T, Nixon R, Tam M and Tate B. Allergy to tea tree oil: retrospective review of 41 cases with positive patch tests over 4.5 years. Australasian Journal of Dermatology (2007) 48; 83-87

    Aberer W. Contact allergy and medicinal herbs. Journal of the German Society of Dermatology (2008) 6; 15 -24
    Last edited: Dec 21, 2008
  21. Don ESWT

    Don ESWT Active Member

    Three cheers for the 'Scots' he's a great Glaswegian our Billy

    Don Scott

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