Is cryotherapy a suitable treatment option for an elderly patient with lesions in the right parietal area and the borders of a previous lesion on the left orbital, considering their age, skin type, and history of sun exposure?

Cryotherapy for Parietal and Orbital Lesions

Cryotherapy is an appropriate and effective treatment for these two lesions, provided they are low-risk basal cell carcinomas (BCCs) or actinic keratoses (AKs), with the critical caveat that the orbital lesion location requires careful assessment to ensure it does not involve the lid margin or external auditory meatus. 1

Lesion Selection Criteria

The success of cryotherapy fundamentally depends on proper lesion selection and operator experience 1:

• Low-risk BCCs achieve 99% five-year cure rates with double freeze-thaw cycles in expert hands 1
• Periocular BCCs can be treated with cryotherapy, with one series of 158 lesions showing 8% recurrence after 5-year follow-up, but careful selection is crucial 1
• High-risk features that predict treatment failure include large size, morphoeic histology, and involvement of the lid margin 1
• Recurrent lesions at the borders of the previous left orbital lesion represent a relative contraindication, as cryotherapy shows only 60% five-year cure rates for recurrent BCCs 1

Treatment Protocol

For the right parietal lesion 1:

• Apply double freeze-thaw cycles with tissue temperatures reaching -50 to -60°C
• Single treatment cycle may suffice if the lesion is superficial and truncal
• Expected healing time: 35-46 days 2

For the left orbital lesion (borders of previous treatment) 1:

• Critical assessment required: If this involves the lid margin, cryotherapy is contraindicated 1
• If the lesion is truly at the borders and not involving high-risk anatomical structures, double-cycle cryosurgery is appropriate 1
• Potential complications include conjunctival hypertrophy and ectropion requiring corrective surgery 1

Post-Treatment Management

Immediate care 2, 3:

• Apply topical antibiotic ointment for 3-7 days to prevent secondary bacterial infection (occurs in ~25% of cases)
• An eschar will form within 1-3 days and must not be picked or forcibly removed 2
• The treated lesion will fall off within 2-4 weeks 2

Monitoring for complications 2, 3:

• Secondary bacterial infection is the most common complication, requiring systemic antibiotics if topical therapy fails 2
• Watch for increasing erythema, purulent drainage, increasing pain, warmth, or systemic symptoms 3
• Pigmentary changes (hypo- or hyperpigmentation) may persist for 6-12 months 4

Critical Caveats

The recurrent nature of the left orbital lesion is concerning 1:

• Recurrent BCCs have significantly lower cure rates (60% vs 92.3% for primary lesions) 1
• Consider alternative treatments such as surgical excision or Mohs micrographic surgery for better outcomes in recurrent disease 1

Anatomical considerations for orbital lesions 1, 4:

• Avoid cryotherapy on eyelids, nose tip, lips, and cartilaginous structures where complications are more problematic 4
• The skill of the operator is critical to success and safety 4

Repeat treatment expectations 2, 3:

• Approximately 50% of lesions clear with a single treatment 2
• If lesions do not completely resolve after the eschar falls off, repeat cryotherapy at 3-week intervals may be necessary 2, 3
• Reassess at 4-6 weeks to determine if repeat treatment is indicated 3

Alternative Considerations

Given the recurrent nature of the left orbital lesion, surgical excision should be strongly considered as it provides histological confirmation and potentially superior cure rates for recurrent disease 1. The British Association of Dermatologists guidelines indicate that excision has lower recurrence rates than cryotherapy for challenging lesions 1.