Primary care physicians are asked more and more today to perform procedures that previously were done exclusively by specialists. Reasons include the higher cost of specialty care, the inability to access certain specialists in a timely manner, and even the need for primary care doctors to improve practice revenue by offering expanded services in a deteriorating healthcare market. One area that physicians are providing more frequently and profitably is cryosurgery in the outpatient setting. There are 3 basic commercially available cryosurgical systems in use at present. They are liquid nitrogen, Verruca-Freeze and Histofreezer. We will examine the indications, contents, effective temperature, method of application and other details associated with each of these systems. Liquid Nitrogen was the original cryosurgical technique used. Indicated for benign lesions (warts and actinic keratosis), and cancerous lesions (early squamous cell carcinoma and basal cell carcinoma), it is non-flammable liquefied nitrogen, a natural element first liquefied in 1884. Effective temperature is -196 degrees Centigrade (C.) and must be stored in large dewars (which are not portable) and require appropriate withdrawal and safety gear, although spray devices are portable. Shelf life is 3-6 weeks and refills may require special delivery from a local gas company. Application for liquid nitrogen is 2-6 seconds with handheld spray device. Spray tips or cotton swabs are used to apply the nitrogen, although the effective temperature drops to -20 degrees (C.) with the cotton swab. Costs vary depending on how frequently the liquid nitrogen is used. Verruca-Freeze ™(produced by CryoSurgery, Inc.) is another commercially available portable cryosurgical compound. It is composed of a non-flammable mix of trifluoroethane, pentafluoroethane and tetrafluoroethane and is indicated for 21 specific benign lesions including: verruca vulgaris (warts) and verruca plantaris (plantar warts), seborrheic keratosis, actinic keratosis, achrochordon (skin tags), molloscum contagiosum, lentigo (age spots), condyloma acuminata (HPV genital warts), dermatofibroma, small keloids, granuloma annulare, porokeratosis plantaris, angiomas, lentigo maligna, keratoacanthoma, lentigo discrete, chondrodermatitis, epithelial nevus, leukoplakia, and pyogenic granuloma. Verruca-Freeze has an effective temperature of -70 degrees (C.) and comes in a variety of starter kits and replacement canisters. Shelf life is a minimum of 5 years. Kits and canisters are portable and have no hazmat fees for delivery. Application is for 20-30 seconds including spray time. A combination of limiting soft tips (3, 5, 7, 9 and 12 mm) and disposable cryobuds (small, medium and large) come with all starter kits and replacements are available. Accessories also include patient instruction pads and CPT coding information. Video training is available on manufacturer’s website. Cost is fixed based on number of applications obtained from each canister and number of cryobuds used. Histofreezer ™(produced by Orasure Technologies, Inc.) is a commercially available portable cryosurgical compound. It is composed of a flammable combination of dimethyl ether, propane and isobutene and is indicated for 9 benign lesions including: verruca vulgaris (warts) and verruca plantaris (plantar warts), seborrheic keratosis, actinic keratosis, achrochordon (skin tags), molloscum contagiosum, lentigo (age spots), and condyloma acuminata (HPV genital warts). Histofreezer has an effective temperature of -55 degrees (C.) and comes in variety of portable sizes, although the larger size kits have hazmat fees when purchased. There are no replacement canisters. Shelf life is 2-3 years. Application is for 40 seconds including spray time. Application is via disposable 2 and 5 mm buds which come with each kit. Accessories include detailed instructions with CPT codes and MSDS information available. Cost is fixed based on number of applications obtained from each kit. In conclusion, doctors’ offices and clinics can now provide quality cryosurgery for minor but bothersome lesions in an outpatient setting at reasonable cost with a variety of cryosurgical systems. The longevity of the newer compounds (Verruca-Freeze and Histofreezer) make them appealing candidates for helping primary care doctors improve their patients access to needed timely treatment while also improving practice revenue. A “win-win” situation for all involved.
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