A long time ago…in a land far, far away, called Tripler Army Medical Center in Hawaii, I was chief of the Dermatology clinic. We provided medical support not only for all branches of the military but also for veterans (VA). My backlog for VA patients was 6 months. Because of this I was very aggressive in treating Actinic Keratosis (AK) with many modalities, particularly liquid nitrogen. I would treat over 100 to 200 lesions in patients with severe sun damage with excellent results. What I discovered was that the more aggressive I was in treating AKs the fewer surgeries I had to do for Basal Cell Carcinomas and Squamous Cell Carcinomas, the most common types of skin cancers developing from premalignant lesion such as AKs. It takes a lot more time to do surgery and I can treat many more patients in the time it would take to perform these surgeries.
Insurance: So, why don’t other dermatologist treat 100-200 lesions on severely skin damaged patients? The answer to that question is…insurance. When billing out for the treatment of AKs the code for treating 15 or greater lesions is 17004, which is a global charge. In other words, the doctor does not get paid anymore for any lesions treated over 15 total for a single visit. Treating more than 15 lesions in a single clinic visit costs the doctor more in liquid nitrogen and time. There is no incentive to treat more.
So, any lesions treated over 15 per a single clinic visit are free. I do a lot of free AK treatment, but I will compare my patients any day to dermatologists that do not treat this way. There are alternative field treatments that can be done with very good results, such as Efudex (5-Fluorouracil), phototherapy (Blue Light, Red Light), Klisyri (Tirbanibulin), Aldara (Imiquimod), etc., however they are limited by 1) size of treatment areas, 2) marked inflammatory responses (refer to my post on this under Actinic Keratosis), 3) longer recovery times, and 4) potential scarring in patients with very fulminant reactions.
Many of my patients prefer aggressive liquid nitrogen therapy over other treatment options, including phototherapy, because of the quick recovery times and the more generalize treatment I am able to offer (multiple locations). In a single clinic visit I often treat AKs on the hands, arms, face, vertex, chest and back with excellent and very cosmetic results. I hope this explains why I am so aggressive in the use of liquid nitrogen in treating AKs. To this day I still judge my success in treating AKs by how often I have to biopsy and surgically excise Basal Cell Carcinomas and Squamous Cell Carcinomas in my patients.