RHSC
Protocol 8.1
CRYOTHERAPY TO WARTS PROTOCOL
RHSC PROTOCOL 8.1
Yorkhill Division
Nursing and Midwifery Policy committee
Policy Number: RHSC PROTOCOL 8.1
Policy Name:
CRYOTHERAPY TO WARTS
Personnel policy applies to
This policy applies to all registered nurses working within the dermatology nursing
service within the Yorkhill Division of NHS Greater Glasgow.
STATEMENT
As a registered nurse, the designated nurse is personally accountable for his/her own
practice and in exercising accountability may therefore enhance his/her own skills by
performing cryotherapy to warts. This document authorises cryotherapy treatment by
the defined group of nursing staff who meet the criteria for the inclusion under the terms
of the document.
1.0 Protocol
The designated nurse will work in partnership with dermatology medical staff, and will at
all times assess and prioritise duties, seeking the co-operation of medical staff when
necessary to ensure patients needs are met.
2.0 Characteristics of the Nurse Performing Cryotherapy
The designated nurse will be deemed competent by:
 Receiving in house theoretical and practical training and assessment from
dermatology sister/consultant, achieving at least level 5 competency (See attached
training pack).
 Observing at least five patients diagnosed as having warts being treated with liquid
nitrogen. Subsequently, the designated nurse should have competently treated a
minimum of five patients with facial warts in addition to five other patients with hand
and foot warts under supervision.
 Demonstrating capabilities with regard to safe and competent practice and agreeing
to continuous assessment with regards to wart cryotherapy.
 Completing a “Record of Practice Development” form with evidence of at least yearly
reviews.
The designated nurse must adhere to the following:
 NMC Code of professional conduct (2004)
 NMC Scope of professional practice (2002)
 NMC Guidelines for the administration of medicines (2004)
 NMC Guidelines for records and record keeping (2004)
 NHS Greater Glasgow Standard Precautions Policy (2005)
 NHS Greater Glasgow Clinical Waste Disposal Policy (2005)
 Yorkhill Division Outpatient Department guidelines on the safe handling and storage
of liquid nitrogen (2003)
 Control of Substances Hazardous to Health regulations (1994)
 Children (Scotland) Act (1995) HMSO
 Age of Legal Capacity Act (1991) HMSO
 Data Protection Act (1998)
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RHSC PROTOCOL 8.1
3.0 Conditions Under Which the Protocol Can be Used
Criteria for Inclusion
 Patient presenting with viral warts diagnosed and referred by a medical practitioner.
 Patient wishing and allowing treatment to be carried out, written consent must be
obtained.
Criteria for Exclusion
 Patient referred by nursing staff
 Patient not wishing or allowing treatment to be carried out
Good Practice Guidelines for Cryotherapy to Warts are attached for reference and to
enhance the safety and quality of practice.
4.0
Supporting Literature
Champion RH, Burton JL, Ebling FJG (1993) Textbook of Dermatology Volume 2 5th
Edition Blackwell scientific Publications Oxford
Dawber R, Colver G, Jackson A (1997) Cutaneous Cryosurgery: Principles and Clinical
Practice 2nd Edition Dunitz London
Kuwahara RT (2003) Cryotherapy www.emedicine.com/derm (accessed 04/11/03)
5.0
Authors
Lizanne McInnes, Dermatology Sister
Anne Speirs, Dermatology Sister
6.0
Ratification
Director of Nursing and Patient Services
Signature:
_____________________________________
Date:
_____________________________________
October 2005
Review Date October 2007
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CRYOTHERAPY TO WARTS
TEACHING PACKAGE
3
CONTENTS
Page
2
Aims and Objectives
3
Human Papilloma Virus (HPV)
Types of Wart
4
Viabilty, Transmission, Treatment
5
Home Treatment
6
Cryotherapy Treatment
Liquid Nitrogen and Cell Interaction
7
Side Effects and Complications
8
Hazards Associated with Liquid Nitrogen
Hazards (cont)
9
Competencies for Performing Cryotherapy
10
Competencies (cont)
11
Assessment Criteria
12
Assessment
13
Record of Supervised Practice
14
Record of Supervised Practice (cont)
15
Record of Assessment and Training
4
AIMS AND OBJECTIVES
Aim
To provide a core knowledge in the treatment of warts using liquid nitrogen.
Objectives
-
To develop an understanding of the wart virus.
-
To understand first line treatment of warts.
-
To understand the principles of cryotherapy and tissue interactions.
-
To understand the hazards associated with the use if liquid nitrogen.
-
To understand the risks, benefits, possible complications and side effects
associated with liquid nitrogen.
-
To be able, after study of the above issues, to answer the theoretical sections
of the liquid nitrogen competency assessment.
5
Wart Biology
Human Papilloma Virus HPV)
Warts are benign epidermal tumors produced by the human papillomavirus
(HPV) infection of the skin and mucous membranes.
There are around 60 different types of HPV that cause warts, each type
preferring a specific skin location. In children they are seen most commonly on
the fingers, hands, feet and face but can appear anywhere on the body.
Types of wart
Common wart: a firm raised lump with a rough surface. Often seen in isolation
or in clumps on the knuckles, knees and nail folds.
Plantar wart: affect the soles of the feet, commonly called verrucas.
Periungual wart: affect under and around the nails.
Filiform wart: long, slender growths on lips, eyelids, face or neck.
Plane wart:: smooth, flat topped or slightly raised, affecting face or back of
hands.
Mosaic wart: this is a collection of small warts grouped together in a cluster.
Genital wart: these are warts affecting the genital area and can be sexually
transmitted but not always. Can also be passed from mother to baby during
delivery if mum has vaginal papillomavirus infection at time of delivery.
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Viability
Heating to temperatures above 55°c inactivates the virus. The virus can be
stored at -25°c for many months without losing its activity.
The incubation period varies from 1 to 3 months and possibly up to several years.
Transmission
Warts are spread by direct or indirect contact. Impairment of the epithelial barrier
function, by trauma (including mild abrasions), maceration or both, greatly
predisposes the individual to inoculation of the virus, and is generally assumed to
be required for infection at least in fully keratinisied skin.
Warts can also spread on the same person. Proximity of other warts is important,
new warts occur more readily in areas with warts present than without.
Whether a wart will develop as a result of inoculation with infected materials will
depend on the amount of virus present and the immunity of the individual towards
the virus.
Treatment
Routine treatment of warts is not necessary. They are harmless and do not
compromise the patients’ health. Most will resolve spontaneously without trace
within 6 –18 months, although some patients’ warts can present for 3 – 5 years
and in a minority of patients they can persist for longer.
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Home Treatment
Patients should be informed about their condition and advised on how to reduce
the risk of cross infection. Once they have a basic understanding of the virus the
more likely they are to be successful in treating it successfully.
Treatment of warts at home is time consuming and requires perseverance and
commitment from the patient. Topical treatments used contain salicylic acid and
should be applied every night for up to 12 weeks. Salicylic acid works by
destroying the keratin that makes up the wart. These treatments should not be
used on the face or genital area, as irritation is likely.
Filing down the hyperkeratotic wart is essential as this enables the topical
treatment to penetrate the epidermis and reach the wart virus. The gentle use of
a pumice stone or emery board is helpful in the removal of the surface keratin.
However over enthusiastic abrasion is common and may enhance the spread of
the virus by inoculation into adjacent skin. It is also thought that the gentle
abrasion of the skin when removing the keratin may also stimulate an immune
response to the virus.
An accurate application of salicylic acid preparation is essential to avoid
damaging normal skin. This can be achieved by using a fine applicator or
protecting the surrounding skin with vaseline. If topical treatment comes into
contact with healthy skin surrounding the wart it can cause irritation. Stopping
application for a few nights and being more careful when applying the solution
can usually control this. Penetration into thick keratin, such as that on the sole
of the foot, can be enhanced by occlusion, which promotes maceration of the
keratin layer and reduction of the barrier function.
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Salicylic acid preparations should be used for at least 3 months, if this is
ineffective treatment with liquid nitrogen may be considered as the next stage
depending on the age of the child and their level of understanding.
Cryotherapy Treatment using Liquid Nitrogen
The goal of cryotherapy is to freeze and destroy unwanted targeted skin growths
e.g warts, while preserving the surrounding skin.
Liquid nitrogen is a second line treatment used to treat warts if topical treatments
have been unsuccessful or as a first line treatment for facial and genital warts.
Treatment is repeated every 3 weeks for 10 treatments, this allows any
inflammation from the previous treatment to resolve. If treatment is reduced to 4
weekly or longer the cure rate drops dramatically and the treatment becomes
much less effective, therefore regular attendance is essential.
Liquid Nitrogen and Cell Interaction
Extra circular ice damages cell membranes. Intra circular ice also forms in many
cells during freezing and is thought to damage mitochondria and endoplasmic
reticulum. Large ice crystals are more damaging than small ones. Slow thawing
is associated with re-crystallisation of ice and this approach is known to be more
destructible that rapid thawing. An immune response to the wart virus develops
in patients whose warts have been treated with several cryotherapy treatments.
Destruction of the tissue does not effect a cure unless the virus is also
eradicated, so this immunological response is important.
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Side Effects and Complications Associated with Liquid Nitrogen Treatment
Pain and Inflammation: whilst warts are being frozen the patient will experience
a burning sensation. As the wart thaws out it begins to throb and continues to do
so for a variable time. The degree and duration of discomfort depends on the
length of freeze and the patients’ level of pain tolerance. A simple analgesia
such as paracetamol is recommended if pain persists.
Blistering: water blisters or occasionally haemorrhagic blisters may develop
within a day or two. These can be punctured using a sterile needle and the fluid
drained to reduce pain and discomfort.
Pigmentary Changes: Hypopigmentation of the area treated can occur, more
common in darkly pigmented patients. Hyperpigmentation can also occur. Both
generally only last for a few months, but can be longer lasting.
Nerve Damage: this is possible but rare, particularly in areas where the nerves
lie close to the surface of the skin, such as sides of the fingers, the wrists and the
area behind the ears. It has been reported that this will resolve within a few
months.
Hazards Associated with Liquid Nitrogen
Liquid nitrogen boils at - 196°c and will explode if kept in a totally sealed
container, the storage vessel is designed to allow some evaporation.
The main hazard to the practitioner is when decanting from the storage unit to the
flask.
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When decanting liquid nitrogen from the storage vessel:
-
Protective clothing must be worn: specialist gloves are worn to prevent frost
burns and goggles must be worn due to the risk of splashing.
-
The room must be well ventilated as liquid nitrogen forms an oxygen deficient
atmosphere.
The Yorkhill Division Outpatient Department ‘Guidelines on the Safe handling
and Storage of Liquid Nitrogen’ must be adhered to at all times.
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Competencies for Performing Cryotherapy
Theoretical Competencies
The nurse will:
1. Demonstrate knowledge of various types of warts and their biology
2. Demonstrate knowledge of mode of transmission and virus viability.
3. Describe with understanding first line treatments and their effectiveness.
4. Discuss the possible complications and side effects of cryotherapy.
5. Discuss the safety issues involved with cryotherapy treatment and
describe the care that must be taken with liquid nitrogen.
Practical Competences
The nurse will:
1. Competently and safely fill Cryovac ® from the storage vessel.
2. Is able to select the appropriate method to treat wart depending on body
site.
3. Effectively prepare the patient physically and psychologically for
cryotherapy treatment.
4. Manual dexterity when performing treatment.
5. Advise the patient on the appropriate after care required and inform them
of any possible side effects. Provides patient with patient information
leaflet on cryotherapy.
6. Accurately document the treatment and any improvement or deterioration
in the patients medical notes.
7. Recognise and discuss the main side effects and complications of
treatments (topical and cryotherapy).
8. Make appropriate referral to medical staff in the event of any complications
or treatment being unsuccessful.
9. Demonstrate organisational awareness by good time management of lists
and ensuring all equipment required for cryotherapy is available.
Lizanne McInnes - Dermatology Sister (April 2005)
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ASSESSMENT CRITERIA
LEVEL OF ACHIEVEMENT
Novice
Cannot perform this activity
Can perform this task but not without
constant supervision and assistance
Advanced
Beginner
Can perform this activity satisfactorily
but requires some supervision and
assistance.
Competent
Can perform this activity satisfactorily
without supervision or assistance.
Can perform this activity satisfactorily
without supervision or assistance with
more than acceptable speed and quality
of work.
Proficient
Expert
Can perform this activity satisfactorily
with more than acceptable speed and
quality and with initiative and adaptability
to special problem situations.
Can perform this activity with more than
acceptable speed and quality, with
initiative and adaptability and can lead
others in performing this task.
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GRADE
0
1
2
3
4
5
6
ASSESSMENT
Theoretical Competencies
No 1.
0
1
2
3
4
5
6
No 2.
0
1
2
3
4
5
6
No 3.
0
1
2
3
4
5
6
No 4.
0
1
2
3
4
5
6
No 5.
0
1
2
3
4
5
6
Circle appropriate score
Practical Competencies
No 1.
0
1
2
3
4
5
6
No 2.
0
1
2
3
4
5
6
No 3.
0
1
2
3
4
5
6
No 4.
0
1
2
3
4
5
6
No 5.
0
1
2
3
4
5
6
No 6.
0
1
2
3
4
5
6
No 7.
0
1
2
3
4
5
6
No 8.
0
1
2
3
4
5
6
Circle appropriate score
Date of assessment : ……………………………………………………
Signature of supervisor: ………………………………………………...
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RECORD OF SUPERVISED ASSESSMENT AND PRACTICE
The dermatology sister or consultant will demonstrate at least five patients
diagnosed as having warts being treated with liquid nitrogen. Following this the
designated nurse will competently treat a minimum of five patients with facial
warts, five patients with hand warts, five patients with plantar warts and five
patients with genital warts under supervision adhering to the Cryotherapy Good
Practice Guidelines.
Hand warts
Supervisors signature
Date
Attempt 1 …………………………………..
…………………….
Attempt 2 …………………………………..
…………………….
Attempt 3 …………………………………..
…………………….
Attempt 4 …………………………………..
…………………….
Attempt 5 …………………………………..
…………………….
Plantar warts
Supervisors signature
Attempt 1 …………………………………..
…………………….
Attempt 2 …………………………………..
…………………….
Attempt 3 …………………………………..
…………………….
Attempt 4 …………………………………..
…………………….
Attempt 5 …………………………………..
…………………….
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Facial warts
Supervisors signature
Date
Attempt 1 …………………………………..
…………………….
Attempt 2 …………………………………..
…………………….
Attempt 3 …………………………………..
…………………….
Attempt 4 …………………………………..
…………………….
Attempt 5 …………………………………..
…………………….
Genital warts
Supervisors signature
Date
Attempt 1 …………………………………..
…………………….
Attempt 2 …………………………………..
…………………….
Attempt 3 …………………………………..
…………………….
Attempt 4 …………………………………..
…………………….
Attempt 5 …………………………………..
…………………….
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RECORD OF ASSESSMENT AND TRAINING FOR ADVANCED
PRACTICE SKILLS
………………………………………………………………………………………………
has had the appropriate training and supervision and has been deemed
competent to perform cryotherapy to warts.
ASSESSORS SIGNATURE
DATE
…………………………………………
……………………….
PRACTITIONERS SIGNATURE
DATE
…………………………………………
……………………….
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