Successful management of treatment-resistant multifocal epithelial hyperplasia with contact cryosurgery: A case report

Dear Editor, We present the case of a 21-year-old woman diagnosed with multifocal epithelial hyperplasia (MEH), also known as Heck’s disease, a rare benign condition of the oral mucosa. Symptoms started at age 10 years, and the lesions grew over time. Six years ago, the diagnosis of MEH was histopathologically confirmed by a biopsy taken at another center. After the diagnosis, the patient underwent multiple open-technique cryotherapy sessions and used topical imiquimod and retinoic acid, but there was no significant improvement. Upon dermatologic examination, multiple papules and plaques were observed on the upper and lower lip mucosa and the bilateral buccal mucosa, ranging in size from a few millimeters to 2 cm. Given the failure of previous treatments, we opted to apply contact cryosurgery, a method that offers precise control over lesion-specific damage while reducing the risk of side effects associated with nitrogen overflow. The mouth was cleaned with 70% ethyl alcohol before each procedure. In contact cryosurgery, 6 mm and 10 mm diameter cryoprobes were used depending on the lesion size. The cryoprobe was frozen in the air until the freezing ring was seen before contacting the lesion. The frozen cryoprobe was placed directly on the lesions for 10–30 s, depending on the lesion size, and applied until a freezing ring was seen in the lesion [Figure 1]. The frozen cryoprobe was gently and carefully detached from the lesion. In cases where separation proved difficult, the contact was safely terminated by warming the cryoprobe using sterile gauze. Anesthesia was not used due to the patient’s pain tolerance. We performed contact cryosurgery on all lesions present at each session. Significant improvements were noted after the first session, and complete regression was achieved after six sessions [Figure 2]. Mild pain and tenderness were the only side effects noted. The patient has been under regular follow-up for 30 months without any signs of recurrence.Figure 1: The cryoprobe was precooled in the air until a visible freezing ring formed around the tip. Depending on the lesion size, it was applied directly to the lesion for 10–30 s. The cryoprobe was applied until a freezing ring appeared within the lesion, indicating effective tissue freezing.Figure 2: Clinical photographs of the patient’s oral mucosa before treatment (a and b) and after six sessions of contact cryosurgery (c and d). (a and b) Illustrate the multiple papules and plaque lesions on the upper and lower lip mucosa before treatment. In contrast, (c and d) demonstrate complete regression of the lesions following the cryosurgery sessions. The patient exhibited no recurrence during the 30-month follow-up period.MEH is associated with human papillomavirus subtypes 13 and 32 and is often linked to contributing factors such as genetic predisposition, poor hygiene, and immunosuppression.[1,2] Diagnosis is typically based on clinical findings and confirmed through histopathology. While there are several treatment options, including surgical excision, cryosurgery, electrocoagulation, electrodesiccation, laser therapy, and topical agents, no gold standard treatment has been established, and MEH can progress into chronic lesions in some cases. Cryosurgery, particularly the contact technique, is a well-established method in dermatology, causing tissue destruction through ischemia and cellular membrane disruption. Contact cryosurgery provides better control over the freezing process compared to the open technique, minimizing nitrogen overflow and reducing the risk of side effects. The freezing process, which reaches temperatures as low as − 22°C, allows for sufficient freezing depth, causing cryonecrosis and leading to complete lesion destruction.[3] In this case, contact cryosurgery was highly effective in achieving full lesion regression in a patient whose MEH had been resistant to prior treatments. Due to its ability to deliver controlled, lesion-specific damage while achieving complete lesion regression, this case further supports the long-term efficacy of contact cryosurgery in treating MEH, as no recurrence was observed over a 30-month follow-up period. In addition, the lack of significant side effects and the durable therapeutic outcomes reinforce the viability of this method, particularly in patients unresponsive to conventional therapies. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Data availability statement The datasets generated during and/or analyzed during the current study are publicly available. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.